.

Membership Application

Fields marked by * are required.

1. New or Renewal * New Membership     Membership Renewal 2. Name * 3. Degree * 4. Place of Employment 5. License(s) * 6. Office Address * 7. Principal Geographic Area * Allen   Carrollton   North Dallas   South Dallas   Downtown Dallas   Farmers Branch   Garland   Irving   Lakewood   Mesquite   North Richland Hills   Oak Lawn   Plano   Richardson   Rockwall   Lewisville   Denton   Arlington   Other   8. Office Phone * 9. Office Fax 10. Email * 11. Specialties 12. Home Address 13. Home Phone 14. Home Fax 15. Type of Membership * LMFT  $40 Non-LMFT  $40 Retired  $20 Student  $20 Intern  $30 Pac Donation  (optional/any amount) CEU only fee  $10 per session 16. If you are unable to receive the DAMFT Newsletter by email, how would you like to receive it? Fax Newsletter to Mail Newsletter to After submitting this application, remember to MAIL the appropriate dues to: Gloria Martin, MA, LPC, LMFT 7502 Greenville, Suite 500 Dallas, TX 75231