CHILDREN'S SERVICES NETWORK
MEMBERSHIP APPLICATION
MEMBERSHIP YEAR: _________________
NAME: ______________________________________________________________________________
DEGREE: ____________________________________________________________________________
AZ State License #: _____________________________________________________________________
PROFESSION: ________________________________________________________________________
(Students, please list your school and degree program)
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SPECIALTY: _________________________________________________________________________
BUSINESS ADDRESS
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
PHONE _____________________________________________________________________________
E-MAIL ADDRESS* ____________________________________________________________________
*Note: Please be sure to include your email address so that we can add you to the website.
Suggestions for speakers (please volunteer) and topics: _______________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
FEE: $50 initial fee; $30 for students
Checks may be mailed to:
Dr. Lanie Zigler
2633 E. Indian School, Suite 310
Phoenix AZ 85016
SIGN HERE to indicate your consent to list information in the CSN online directory:
____________________________________________________ DATE: __________________________
BY SIGNING THIS FORM I ATTEST THAT I AM LICENSED IN ARIZONA BY THE APPROPRIATE AGENCY GOVERNING MY PROFESSION AND AM IN GOOD STANDING WITH THIS AGENCY. THE NETWORK NEITHER ENDORSES SPECIFIC PRACTITIONERS NOR VERIFIES CREDENTIALS. THE EXECUTIVE COMMITTEE RESERVES THE RIGHT TO DENY MEMBERSHIP AT THEIR DISCRETION.
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