American Correctional Association (ACA): Membership

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ACA Membership Application Form

Membership is open to all individuals and organizations with interest in the correctional field.

STEP 1. ENTER YOUR NAME AND EMAIL ADDRESS (* REQUIRED FIELDS)

First Name	Last Name

Email Address

Have a Household member joining or renewing with you at this time? Name them here:

First Name	Last Name

Email Address

# Household memberships in Professional I, Professional II and Executive Gold Card offer one year of benefits for two individuals living at the same HOME address. While both Household Members will receive an ID card and certificate, only one copy of each magazine, newsletter or directory offered as a benefit will be sent under this program.

STEP 2. SELECT A MEMBERSHIP CATEGORY

Membership categories are based upon how much you would like to receive as a member in a given year. Click on the membership categories� names for benefit details. There are 4 individual membership types (one for students/retirees) and 2 corporate/facility membership types. In addition to joining as an individual member, you may also elect to join the Healthcare-Professional Interest Section for an additional $25 (but you must select an ACA individual membership-type first)

A. MEMBERSHIP CATEGORIES (Select One � CLICK ON NAME FOR BENEFIT INFO) ( U.S. , U.S. TERRITORIES and CANADA ONLY)
INDIVIDUAL	*1 YEAR*	*3 YEAR*	Household*
PROFESSIONAL I	$35	$99	$55*
PROFESSIONAL II	$75	$215	$115*
EXECUTIVE GOLD	$100	$290	$150*
ASSOCIATE**	**$15 ****

* Household membership offers one year for two individuals at the same HOME address. Only one copy of each magazine, newsletter or directory offered as a benefit as part of this program. You must name the secondary
** (Associate membership is for students, retired professionals, and volunteers or those not currently working in corrections ONLY; subject to verification)

ORGANIZATIONAL		1 YEAR
ORGANIZATIONAL	(Non-profit entities)	$300
SUPPORTING PATRON	(For-profit entities)	$350

INTERNATIONAL DUES (SELECT ONLY IF YOUR ADDRESS IS OUTSIDE THE US , ITS TERRITORIES OR CANADA )

*INDIVIDUAL*	*1 YEAR*	*3 YEAR*	*ORGANIZATIONAL*	*1 YEAR*
PROFESSIONAL I	$50	$140	ORGANIZATIONAL	*$390*
PROFESSIONAL II	$110	$320	(Non-profit)
EXECUTIVE GOLD	$150	$440	SUPPORTING PATRON	*$440*
ASSOCIATE**	$25 **		(For-profit)

B. PROFESSIONAL INTEREST SECTION (optional, but you must select a member type from above in order to join this:)

NoYes, I would like to join the Healthcare Professional Interest Section (H-PIS) for an additional $25.

Benefits include: � Subscription to Correctional Health Today � Members-Only Section of the ACA Web site. with an electronic version of Correctional Health Today, discussion boards, links to important health care Web sites and organizations, position statements, and networking and mentoring opportunities. � Discounts on ACA�s certification program, publications, and conferences and workshops. � Dedicated health care training tracks and special events at ACA�s conferences.

STEP 3. ENTER YOUR MAILING ADDRESS

A. SELECT A PREFERRED MAILING LOCATION

Home Work

B. ENTER YOUR MAILING INFORMATION

Home Address:

Address:

City

State

Zipcode

Country

Phone: (###) ###-####

Fax: (###) ###-####

Work Address:

Address:

City

State

Zipcode

Country

Phone: (###) ###-####

Fax: (###) ###-####

C. ADDITIONAL MAILING OPTIONS

Occasionally, we make our members list available to carefully screened companies.

Check here if you would like your name removed from that list.

NEW EMAIL OPTIONS!

Check here if you wish to receive renewal notices by e-mail.

Check here if you would like to receive your On The Line newsletter by e-mail in Adobe Acrobat (.pdf) format.

Discount Coupon Code:
(Do you have a coupon code?
Enter it into the box above (One allowed per order): )

STEP 4. SELECT YOUR PAYMENT METHOD AND FINAL INFO

A. PLEASE SELECT A METHOD OF PAYMENT Must select one (if Invoice or Purchase Order is selected, membership will not start until full payment is received) Payment Methods
Credit Card Type	Expiration Date (mmyy)
Card Number *(No spaces, no dashes)*	Amount: $

Please allow four to six weeks for initial receipt of publications. Your membership begins on the 1st of the month following receipt of payment. For example, if we receive your payment on September 5th, you will officially become an ACA member on October 1st. You will receive a renewal notice 60 days prior to your membership's expiration.

You will be billed annually in the month in which you joined. $3.50 of membership dues goes toward a subscription of On the Line; $9 goes toward a subscription of Corrections Today. $14 of Organizations / Supporting Patron / Affiliate memberships goes toward a subscription of On the Line, $36 goes toward a subscription of Corrections Today.

B. WHAT BROUGHT YOU TO THE ONLINE APPLICATION?

Select One:
If it was a friend referral or recruiter who brought you here, give them some credit! (Optional)
Sponsor/Recruiter Name:	Sponsor ACA ID# (if known)
Promo Code:

C. TELL US ABOUT YOURSELF (Optional)

Date of Birth(mm/dd/yyyy)	Area of Corrections

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