Association of Chicagoland Externship and Practicum Training Membership Invoice: 2019-2020 Training Year
Please complete the information below and check the categories that apply by October 31, 2019

A receipt of your participation will be sent to the email address you list below. If you need an invoice for your organization, please print the email receipt or print this form, or email
Email address *
Name of Organization:
Your answer
Director of Training:
Your answer
Your answer
Phone number:
Your answer
Email Address:
Your answer
Voting Representative (each organization is allowed one vote per membership - please indicate your chosen voting member here):
Your answer
Voting Representative Email Address:
Your answer
Please indicate which best describes your membership:
As an ACEPT member, my organization and I hereby support the missions of ACEPT and abide by the ACEPT guidelines.
If you have any questions about the guidelines and/or mission of ACEPT, please contact this year's President Miki Koyama at
Please indicate how you plan to pay ACEPT dues (instructions below):
To pay via check:
1. Mail check (with organization/member name indicated on memo line) payable to ACEPT to the ACEPT Treasurer:

Dr. Audra Marks
Assistant Director of Health and Human Services
Director of Training
Village of Hoffman Estates
1900 Hassell Rd.
Hoffman Estates, IL 60169
To pay via PayPal:
1. Go to the webpage
2. Click on "Membership Resources"
3. Click on "Membership Registration & Login"
4. At the bottom of the page, choose the appropriate program for membership under "Membership Dues"
5. Select "Buy Now" to be directed to the PayPal page
6. Include the name of the site with your PayPal payment
PLEASE NOTE: You must submit your dues payment and complete this form by October 31, 2019 in order to activate your membership for the 2019-2020 training year.
A copy of your responses will be emailed to the address you provided.
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