MSCA Member Payment Form

Please register by filling out the form below...

First name:
Last name:
Middle:
Home street address:
Home city:
Home state:	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Home zipcode:
Home phone:	( ) - -
Home fax:	( ) - -
Employer name:
Employer street address:
Employer city:
Employer state:	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Employer zipcode:
Employer phone:	( ) - -
Employer extension number:
Employer fax:	( ) - -
Preferred mailing:	home work
Email:
Education type:	public private retired
Level:	K-12 Elementary (K-5) Middle/Jr. High (6-8) High School (9-12) Post-Secondary Other
License:	K-12 Elementary (K-5) Middle/Jr. High (6-8) High School (9-12) Other N/A
MN license number:
Div id:	All Divisions Anoka Central Lake Area Minneapolis Metro Northeast Northwest Southeast Southwest St. Paul St. Paul Suburban West Central
Amount paid:	Professional Student
MSCA User name:
MSCA Password:
MSCA Password Re-enter:

• The MN_license number is your counselor license number.
• Professional membership is currently $40 and student is $15.
• Note: Your contact information will be confidential. The information is needed for your membership and will be used strictly for MSCA
• Make sure you select a division from the list. "All Divisions" is just the default.
• Make sure your email is updated and valid! This will be what we use to communicate with you!
• All required fields are bolded. You may update your profile later.