CSWS Membership Application
PLEASE PRINT AND FILL IN ALL APPLICABLE BLANKS
Questions? Please contact Amy Penrod Weir penweir@yahoo.com or telephone 302.573-5112
Date_____________________ Name _______________________________ Title_________________________ (First) (MI) (Last) (i.e. MSW, LCSW, BCD, CADC, etc.)
Birth Date ____/____/____
STATE(S) LICENSURE INFORMATION
State
License #
____________
________________________
Home/Mailing Address (Mail will be sent to your home address unless otherwise specified)
Street
________________________________________________
City
_____________________
Zip
Home Phone
Fax
E-mail
Business #1
Organization Name
___________________
Phone
Business #2
MSW PROGRAM_____________________ YEAR OF GRADUATION_______ DEGREE________ Dues are pro-rated after March 1st. Please select the membership category for which you are applying $130.00 - Full MembershipLicensed or eligible to be licensed, graduate of a Masters Program in Clinical Social Work. $65.00 - Associate Membership Graduate of a Masters Program in Clinical Social Work, not yet eligible for licensure. $65.00 - Emeritus Membership Retired Full Members. $35.00 - Student Membership Matriculating student in a graduate program of Clinical Social Work.
Thank you for joining!
Make check payable to Clinical Social Work Society of DE and return this application and check to CSWSDE P.O. Box 7648Wilmington, DE 19803
