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Accredited Certification Programs by the
National Commission for Certifying Agencies
The American Academy of Certified Forensic Counselors
(ACCFC) is the certification commission of the
National Association of Forensic Counselors (NAFC)
N
ational
A
ssociation of
F
orensic
C
ounselors
P.O. Box 8827 Fort Wayne, IN 46898-8827
260-426-7234 -
Phone
260-426-7431 -
FAX
www.Nationalafc.com NAFC@Nationalafc.com
NON-CERTIFIED NAFC MEMBERSHIP APPLICATION
Thank you for your interest in NAFC Membership. If you have any questions pertaining to this application, please contact us and we will assist you to the
best of our ability.
This application must be completed in its entirety. Incomplete applications received will not be processed until all information is received. No waivers will
be granted for any part of this application.
I understand, agree and acknowledge all of the following:
I have read and understand the minimum requirements for non-certified NAFC Membership. Fees for an application that has not been approved
will be
refunded with the exception of the non-refundable $25.00 application fee. Once an application is approved, no fees will be refunded, in whole or part.
It is my sole responsibility to read and stay apprised of the most current revision of the NAFC Terms of Membership which a
re described in the Application
Attestation attached to this application. The NAFC Terms of Membership are publicly available for download from www.Nationalafc.com and that hard
copies may be obtained upon written request to the NAFC.
I have read, agree to and fully understand the NAFC Terms of Memberships and have signed the Application Attestation attached to this application.
_____________________________________________ _____________________________________________ _________________________
Printed/typed name of Applicant Signature of Applicant Date
C
LINICAL
M
EMBERSHIP
(CM)
• No examination required
•
Minimum of a Master's
Degree
• Active and in good standing
professional state
license/state mandated
certification
in your
profession
• Minimum of two (2) years
(4,000 hrs)
working with
criminal offenders in one or
more of the following
capacities:
Criminal Justice
Legal, defense or
prosecution
Law Enforcement
Corrections
Mental Health
Addictions
Other applicable
profession
$25.00: non-refundable
Application Fee must
accompany application
$95.00: Processing and first year
renewal fee due upon
approval
A separate application must be submitted for each NAFC Membership for which you wish to apply. Please select the NAFC
Membership for which you are applying:
P
ROFESSIONAL
MEMBERSHIP (PM)
• No examination required
• Minimum of a Bachelor's
Degree
• Reserved for professionals
with a m
inimum of two (2)
years (4,000 hrs) working
with criminal offenders in one
or more of the
following
capacities:
Probation/Parole
Legal Profession
Law Enforcement
Corrections
Other Criminal Justice
Profession
$25.00: non-refundable
Application Fee must
accompany application
$95.00: Processing and first year
renewal fee due upon
approval
Research
Membership (RM)
• No examination required
•
Minimum of a Master's
Degree
• Reserved for professionals
involved in research specific
to issues pertaining to the
criminal offender to include,
but may not be limited to:
Behavioral
Cognition
Profiling
Statistical
Medical
Other research
pertaining to the
criminal offender
$25.00: non-refundable
Application Fee must
accompany application
$95.00: Processing and first year
renewal fee due upon
approval
(SM)
• No examination required
• Must be either a full or part
time student
degree in one or more of the
following:
Criminal Justice
prosecution
Law Enforcement
Corrections
Mental Health
Addictions
profession
Must meet NAFC Membership
requirements in order to pursue
certified NAFC Membership after
obtaining degree
$25.00: non-refundable
Application Fee must
accompany application
$95.00: Processing and first year
renewal fee due upon
approval
Revised February 4, 2016
Accredited Certification Programs by the
National Commission for Certifying Agencies
The American Academy of Certified Forensic Counselors
(ACCFC) is the certification commission of the
National Association of Forensic Counselors (NAFC)
N
ational
A
ssociation of
F
orensic
C
ounselors
P.O. Box 8827 Fort Wayne, IN 46898-8827
260-426-7234 -
Phone
260-426-7431 -
FAX
www.Nationalafc.com NAFC@Nationalafc.com
SECTION E – Method of Payment
NON-CERTIFIED NAFC MEMBERSHIP APPLICATION
SECTION A – Contact Information
_____________________________________________________________________________________________________________
First Name M.I. Last Name
_____________________________________________________________________________________________________________
Mailing Address City State ZIP
_____________________________________________________________________________________________________________
Work Phone (REQUIRED) Home Phone (optional) Cell Phone (optional) E-mail Address (REQUIRED)
SECTION B – Current Employment Information
SECTION C - References
Attached to this application is a blank Reference Form. Please print submit one (1) completed Reference Form. References must be professionals working
in your professional field and not related to you. Your reference must hold a minimum of a professionally related Masters degree, hold active and in good
standing professional state licensure and/or state mandated certification, if applicable, and have known you professionally for at least three (3) years.
SECTION D - Education
Current Place of Employment:
Position:
Program Type:
Hours Worked per Week:
Dates Employed:
Supervisor Name:
Supervisor’s Phone No.:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
FROM: _____________________________________ TO: ____________________________________
MM/DD/YYYY MM/DD/YYYY
___________________________________________________________________________________________
___________________________________________________________________________________________
Please indicate your highest educational level and attach a copy of the highest degree you earned from an accredited educational institution.
_____ M.D.
_____ J.D.
_____ Psy.D.
_____ Ph.D.: Major: ____________________________________________
____________________________________________________________________________________________________________________________
University/College Graduated Location
__________________________________________
__________________________________________________________________________________
Year Graduated For Student Membership Applicants ONLY, expected graduating year
_____ Masters: Major: __________________________________________
_____ Bachelors: Major: ________________________________________
_____ Other: _________________________________________________
_____ Student – Concentration: ___________________________________
_____ Check _____ Credit Card _____ Money Order _____ Purchase Order No.: __________________________________________
_______________________________________________
_____________________________________________________________________________
Name as it appears on credit card Billing Address of Credit Card (Address, City, State, ZIP)
________________________________________________________________
____________________________________________________________
Credit Card Number- VISA, MC, Discover ONLY Exp. Date Security Code Amount to Charge
I attest that I am an authorized user of the credit card provided above. I authorize the AACFC, the NAFC Certification Commission, to charge the above credit card.
___________________________________________________________________________
_________________________________________________
Printed Name of Authorized Card Holder/User Signature Date
Revised February 4, 2016
Accredited Certification Programs by the
National Commission for Certifying Agencies
The American Academy of Certified Forensic Counselors
(ACCFC) is the certification commission of the
National Association of Forensic Counselors (NAFC)
N
ational
A
ssociation of
F
orensic
C
ounselors
P.O. Box 8827 Fort Wayne, IN 46898-8827
260-426-7234 -
Phone
260-426-7431 -
FAX
www.Nationalafc.com NAFC@Nationalafc.com
APPLICATION ATTESTATION
I, ________________________________________________________________ attest and affirm that I am the applicant named in this application.
I have read and completed
the contents thereof and all information provided in connection with this application is true, accurate and correct.
I understand, agree to and acknowledge all of the following:
The American Academy of Certified Forensic Counselors (AACFC) is the Certification Commission of the National Association of Forensic Counselors (NAFC), herein collectively
referred to as “NAFC”.
“NAFC Membership” refers to any NAFC issued certification; non-certified Membership and In-Service designation. “NAFC Member” refers to a professional who has been issued
and holds active and in good standing NAFC Membership.
I am required to abide by the NAFC Terms of Membership which is comprised of, but not limited to the: Candidate Handbook, Application Attestation (or Application Affidavit
where NAFC Membership was applied for and obtained by an NAFC Member prior to the elimination of the requirement of a notarized signature on this form)
, Ethical Standards
and Code of Conduct, Policies and Procedures, Request for Renewal and/or Reinstatement Attestation, Terms of Use of the NAFC Logo, NAFC Fee Schedule, Renewal and/o
r
Reinstatement requirements and NAFC Membership requirements.
New and/or existing NAFC Terms of Membership may be implemented and/or revised at any time without notice. It is my sole responsibility to stay apprised of the
NAFC Terms of
Membership. I am subject to the most recent revision of the NAFC Terms of Membership, to include those that may be implemented in the future. All
are available for download
from the NAFC website at www.Nationalafc.com or hard copies may be obtained upon receipt of my written request to the NAFC.
I fully and voluntarily agree to hold the NAFC, AACFC and all past, current and future: Board Members, Directors, Trustees, Committee Members, Commission Members, Officers,
Agents, Staff, Contractual Employees, Presenters, Examiners, and all other persons and/or entities acting as Representatives as granted by the NAFC,
wholly and absolutely
harmless and free from all civil liability for any and all forms of: damages, complaints, actions, sanctions, resulting repercussions, determinations, outcomes and/or consequences
by reason of any action that is within the scope and arising out of the performance of duties in connection with any application, NAFC Membership, renewal or reinstatement
request, the attendant examinations and the grades with respect to any examination, failure of the NAFC to issue or grant NAFC Membership, as well as
any and all other
action(s) and/or determination(s) that may be taken or made by all the aforementioned.
Providing erroneous information of any kind for any reason to the NAFC constitutes a violation of the NAFC Terms of Membership.
I am required to report to the NAFC within 30 calendar days of my notification should I be the subject of or am otherwise directly or indirectly involved in any formal
, informal, civil,
criminal: charge, complaint, investigation, inquiries, arrest, action, conviction, sanction, professionally related civil and/or legal litigation and/or investigation, disciplinary action
and/or any other form of criminal or civil proceeding relating to any allegation of criminal conduct, civil violation, state and/or federal regulatory board violation
, professionally
related allegation of misconduct and any other form of criminal or civil action or proceeding not listed within the NAFC Terms of Membership initiated or brought by any
federal,
state and/or or local authority/agency, professionally related private agency/organization, client, colleague or any member of the public. I am required to keep the NAFC
apprised
on a monthly basis of the most current status of any and all of the aforementioned and submit copies of all public documents related to such to include, but not limited to:
all
actions, judgments, sanctions, determinations and/or any other form of outcome.
Holding active and good standing professional state licensure/state mandated certification is mandatory in order to maintain NAFC Membership, unless I am
exempt from such
according to the NAFC Membership Requirements. I am required to report within 30 days of my notification any formal complaint, charge
, investigation and/or any change of
status of my professional state licensure/state mandated certification. Revocation or suspension of my professional state licensure/state mandated certification will result in the
same against my NAFC Membership.
I am required to submit to proceedings and comply with all directives given by the NAFC in connection with any alleged violation of the NAFC Terms of Membership.
Information obtained by any means whatsoever by the NAFC indicating one or more possible violations of the NAFC Terms of Membership will result in the NAFC initiating
an
investigation or Formal Complaint on its own. Civil and/or legal action beyond sanctioning of an NAFC Membership may be taken if, in its judgment, it determines that such
egregious violation(s) occurred that taking such action is in the best interest of the NAFC, its Certification Commission, any entity or person acting on its
behalf, NAFC Members
and/or the public.
The NAFC may use information in connection with my application, renewal or reinstatement request or any other information collected for non-
identifying research and statistical
purposes.
All NAFC issued certificates and wallet cards remain the property of the NAFC and I am required to return all to the NAFC
, to include any and all copies thereof, within fourteen
(14) calendar days upon demand for any reason.
I am required to notify the NAFC within 30 calendar days of any change of name, address, contact phone numbers, e-mail address and any other inf
ormation maintained by the
NAFC in connection with the NAFC Membership issued to me.
The abuse of alcohol and/or drugs, to include the abuse of prescription drugs, is unacceptable and I shall not engage in such behavior.
Failure to fully comply with the NAFC Terms of Membership, to include all within this Application Attestation, in whole or part, constitutes grounds for immediate denial of my
application, renewal or reinstatement request and/or sanctioning of my NAFC Membership, to include the nullification of any and all benefits resulting
thereof, as deemed
appropriate by the NAFC.
I have read and fully understand the NAFC Terms of Membership.
____________________________________________________ ____________________________________________________ ______________________________
Printed Name of Applicant Signature of Applicant Date
Revised February 4, 2016
Accredited Certification Programs by the
National Commission for Certifying Agencies
The American Academy of Certified Forensic Counselors
(ACCFC) is the certification commission of the
National Association of Forensic Counselors (NAFC)
N
ational
A
ssociation of
F
orensic
C
ounselors
P.O. Box 8827 Fort Wayne, IN 46898-8827
260-426-7234 -
Phone
260-426-7431 -
FAX
www.Nationalafc.com NAFC@Nationalafc.com
REFERENCE FORM
THIS SECTION TO BE COMPLETED BY APPLICANT BEFORE SUBMITTING TO NAMED REFERENCE FOR COMPLETION:
Applicants Name: _______________________________________________ Name of Reference
: __________________________________________
Non-certified NAFC Membership for which Applicant is applying: CLINICAL PROFESSIONAL RESEARCH STUDENT
I hereby authorize the above named Reference to release any and all information requested by the NAFC in order to process
and verify the information
submitted in connection with this application. Further, I agree to hold the NAFC and the above named Reference
wholly and absolutely harmless as it
pertains to the release of any and all information provided by the above named Reference.
______________________________________________________________________ __________________________________________
Signature of Applicant Date
TO BE COMPLETED BY ABOVE NAMED REFERENCE: Do not complete this form until all fields above are completed by applicant.
Thank you for taking the time to assist the applicant in the application process. Please provide the following requested information.
The above information
should already be filled out by the applicant prior to you completing this form. Please return completed form to the applicant. Please be certain to provide the
best daytime number where you can be reached to verify the information provided.
1. □ Yes □ No -- Are you related to the Applicant?
________________________________________________________ Length of time you have known Applicant in a professional capacity?
Months Years
2. FOR SUPERVISOR ONLY: Length of Applicant’s employment: FROM: __________________________ TO: __________________________
MM DD YYYY MM DD YYYY
3. □ Yes □ No -- To your knowledge, has the applicant abused or misused alcohol or any other drugs, prescription or otherwise, while
performing professionally related services?
4. Please provide feedback regarding the Applicant’s professional ability to work in the profession applicable to the above listed NAFC Membership :
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
5.
□ Yes □ No -- I give my favorable recommendation for this Applicant in connection with obtaining the above listed NAFC Membership
If you do not give your favorable recommendation for this Applicant, please tell us why:
___________________
_________________________________________________________________________________________________
____________________________________________________________________________________________________________________
_____________________________________
_______________________________________________________________________________________
Printed Name of Reference Contact Phone No. Current Position Held
____________________________________________________________________________________________
________________________________
Signature of Reference Date
Attached to this application is a blank Reference Form. Please print submit one (1) completed Reference Form. References must be
professionals working in your professional field and not related to you. Your reference must hold a minimum of a professionally related
Masters degree, hold active and in good standing professional state licensure and/or state mandated certification, if applicable, and have
known you professionally for at least three (3) years.
Revised February 4, 2016
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