Please attach a current copy of your Liability Insurance along with this application.
I understand that it is my obligation to maintain any license required in the jurisdictions in which I practice or plan to practice. I attest that all information on this application is accurate, truthful, and correct to the best of my knowledge. I understand that to falsify information is grounds for refusing to allow me into CAC Network or for removal from the CAC Network should I be included.
I understand that through the CAC Network that I will receive referrals and that those referrals will be served to the best of my ability. I understand that my work with CAC referrals will directly reflect on The Center for Apostolic Counseling.
I understand that by joining the CAC Network I will support the CAC through positive promotion via word-of-mouth, social media, professional networks, church-related events, etc… I will financially support the CAC and understand the minimum suggested gift is $144/year or $15/month.
I understand that this application does not guarantee acceptance into The Center for Apostolic Counseling Network.
I authorize any person, organization or company listed on this application to furnish you any and all information concerning my previous employment, education and qualifications for inclusion into the CAC Network.
I also authorize you to request and receive such information. In consideration, I agree to abide by the rules and regulations of the CAC, which rules may be changed, withdrawn, added or interpreted at any time, at the CAC's sole option and without prior notice to me.
I understand that no representative of the CAC has any authority to enter into any agreement for any specified period of time, or to assure or make some other personnel move, either prior to commencement of CAC Network inclusion or after I have become a part of the CAC Network, or to assure any benefits or terms and conditions, or to make any agreement, that is contrary to the foregoing.
I hereby acknowledge that I have been advised that this application will remain active for no more than 90 days from the date it was submitted.