Provisional/Student Form

OKLAHOMA ACADEMY OF COLLABORATIVE PROFESSIONALS

MEMBERSHIP APPLICATION-PROVISIONAL OR STUDENT

FIRST NAME

LAST NAME

FIRM or SCHOOL

Single choice

ATTORNEY

MENTAL HEALTH PROFESSIONAL

FINANCIAL

PROFESSIONAL LICENSE NO.

EMAIL

ADDRESS

TELEPHONE:

Note: Preferred Contact Number

Choose one

Office

Cell

Phone Number

I understand that until I have notified the OACP in writing that all of the requirements are met, I am a provisional or student member and cannot vote on OACP matters or be listed on the website or I am currently enrolled as a student in higher education program.

Membership Type:

Provisional Membership dues $50 per year

Student Membership dues $10 per year

I agree that should I must renew this membership annually each year no later than January 31.

Signature

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Printed Name

Date

To pay online please go to: Provisional Membership dues $50 per year https://buy.stripe.com/7sIaH79lVf4h0Tu8wy

Student Membership dues $10 per year https://buy.stripe.com/28obLbdCb1dr6dO4gj

If you need to pay by check, please email OACPTreasurer@gmail.com with copy to okcollab@gmail.com. so we can ensure your payment is received timely.

Upload Proof of Payment (Screenshot or Paid Confirmation)

I am paying via check.

Follow this email format if paying via check. Subject: Name / Provisional or Student Membership / Check Payment Body: I have submitted an online application form from your website, I would like to pay via check. Let me know what are the next required steps to proceed.