Licensed Professional Counselors Association of North Carolina

New Membership Application

*LPC License # ( enter 0 if not licensed)

Applicant Information

*First Name

*Last Name

M.I .

*Address

Suite/Apt. No

*City

*Zip

*State

County

Home Phone

Home Fax

*Home Email

Membership Information

Are you a National Certified Counselor?

yes

Please List All State and National Associations of which You are a Member

Please list the name of the individual who recommended you join LPCANC:

Agreement *

I, as a Professional Member LPCANC, agree to adhere to the Code of Ethics and Standards of Practice set forth by the North Carolina Board of Licensed Professional Counselors. I certify that I am a LPC in good standing with NCBLPC and that the information provided is accurate to date.

I, as a Student Member of LPCANC, certify that I am a student in good standing in a counseling related graduate education program at

I herein agree to these requirements,

* To qualify for student membership, applicant must email or fax a copy of their current student ID or transcript to 888-287-1403 or . An application will not be considered valid until one of these is received.

* No agreement required for Associate Membership.

Communication Preferences

LPCANC provides most of our news, event notices and updates about the organization and related matters via email and/or fax. This expedites information sharing and reduces our costs. Please indicate below which address you would prefer for each:

Send mail to my:

Send email to my:

Send faxes to my:

Preferred Phone:

Website Directories

LPCANC publishes two directories on its website (www.lpcanc.org): a Membership Directory and a Referral Directory. Members can find each other by name in the Membership Directory. Consumers can find practitioners by the practice demographics listed below and by city in the Referral Directory. Please indicate how, if at all, you would like to be listed in either directory by selecting from the options listed:

List My Preferred info in the Membership Directory:

List My Preferred info in the Referral Directory:

Work Information - leave blank if not used

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