Membership Application - 2012 Northeast Mediation Conference Attendee

Please enroll me as a new member of The New York State Council on Divorce Mediation for the reminder of the current membership year. I will be attending the 2012 Northeast Mediation Conference.
(Please complete the statement below in agreement)

I, , hereby affirm that I have met the standards for membership as set forth in this application and will adhere to the Model Standards of Practice and NYSCDM By-Laws as posted on the NYSCDM website. If this is a renewal application, I also certify that I have met the continuing education requirements as provided in this application.

 

Membership Enrollment Type





 

Directory Listing Options







Total Due: 		 

 

THIS IS A SPECIAL MEMBERSHIP APPLICATION FOR NEW MEMBERS ATTENDING THE 2012 MEDIATION CONFERENCE

  • First time individual members receive a discount. Membership is $50 for the reminder the membership year.
  • Membership entitles you to a listing on the Council's web page directory.
  • Additional directory listings and active links can be included for an additional fee.
    Option A is free. To be included, please check the appropriate box on the left.

 

Membership Status







Training


Please indicate appropriate proof of mediator status

 

  • Accredited Member is a member who has been granted Accreditation through demonstrated education and experience
  • Mediator Member is any member who has completed comprehensive family and divorce mediation training including a domestic violence component or a mediating family law attorney who has completed basic mediation training and a domestic violence component
  • Affiliate Member is any individual interested in the field of mediation or supporting mediation.

 

Main Contact Information

Full Name:
  
Street Address 1:
  
Street Address 2:
  
City/State/Zip:
      
County:
  
Phone Number
  
Fax Number:
  
Email Address:
  
Would you prefer to receive correspondence by:
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Home Number (Optional):
  

 

Directory Listing

Degrees listed after your name (e.g. Esq., J.D., M.S.W.):
  

Primary Directory Listing

Practice/Company Name:
  

   Use contact information as above
Street Address 1:
  
Street Address 2:
  
City/State/Zip:
      
County:
  
Phone Number:
  
Fax Number:
  
Email Address:
  

 

Additional Directory Listing

Practice/Company Name:
  
Street Address 1:
  
Street Address 2:
  
City/State/Zip:
      
County:
  
Phone Number:
  
Fax Number:
  

 

Payment Method