APPLICATION FOR CERTIFICATION: PART II by tuKkt86

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									                      APPLICATION FOR CERTIFICATION: PART II
                        Statement of Verification and Payment Form


I, (print name)                                                         , verify by my signature below
that the materials I am submitting as part of ACT’s Part II application process are in no way doctored,
unauthentic, plagiarized, or in any way predicated upon deceptive means. I understand that these
materials may be utilized anonymously by ACT for psychometric purposes unless permission to do so is
expressly denied.



Signature of ACT Applicant                                                      Date


Payment Options
 I’ve enclosed a check payable to Academy of Cognitive Therapy for $200.
 I hereby authorize ACT to charge the credit card listed below $200 for Part II of the ACT application
   process


Please check one:
 VISA
 MASTERCARD
                           ACCOUNT NUMBER


                           EXPIRATION DATE


                           SIGNATURE


Cardholder Information:


NAME


ADDRESS


CITY                      STATE                    POSTAL CODE             COUNTRY


BUSINESS PHONE               HOME PHONE                      EMAIL




Please complete and submit this form to the Academy of Cognitive Therapy, along with your Audio
Sample and Case Write Up. All materials should be submitted to the ACT office at:

                                    Academy of Cognitive Therapy
                                   260 South Broad Street, 18th Floor
                                     Philadelphia, PA 19102 USA

								
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