Sign Me Up

Please print the following form, fill-out and mail to NASW-Michigan, 741 N. Cedar St., Lansing, Michigan 48906-5285
Online registration will be available within the next few weeks.

Last Name:                                                                                                                  

First Name:                                                                                                                  

Address:                                                                                                                       

City:                                                                         St:                Zip:                            

Daytime Phone:                                          Alternate Phone:                                   

Email address: (required)                                                                                         

State of Michigan-Licensure Number (Permanent ID #)

680-_____________________________ Expires on:                                      

NASW-Michigan Member ID#:                                                                                  

Non-members pay $40.00:                                                                                       

Charge my credit card:                                                                                               

Visa:                                                          Expires:                                                       

MC:                                                                    Expires:                                                  

Cardholder Signature:                                                                                                 

If billing address if different than above, please indicate here:                          

I am enclosing a check in the amount of: $                                                          

Make all checks payable to NASW-Michigan.  Mail to NASW-Michigan, 741 N. Cedar St., Lansing, Michigan 48906-5285
         
Confirmation of your enrollment in CE Tracking will be sent via email.

Please Note 
You will not have immediate access to your account.  Your online application needs to be processed before your account will be activated, (this may take up to five business days).  Once you receive your email Welcome Letter, you may begin using your online tracking account.