American Correctional Chaplains Association

         Initial         Renewal

Name:     First    MI     Last      

Home: Street or PO Address  

City   State/Province     Zip/Postal Code  

Phone    Home     Cell     Work    Your E-Mail 

Age group:   18-30       30-45         45-60        60-75         75+       I am an: Employee   Volunteer

If renewal only complete items below that have changed since your last application:

Name of Facility     Agency  

Fac. Address  

City   State/Province     Zip/Postal Code  



Faith Credentials   Ordained        Licensed         Elder        Decon         Imam         Rabbi         Other    

Highest Degree   BA        BS         MA        M.Div         D.Min         Ph.D.         Other    

Religion/Faith Group    Denomination  

Endorsing Body    Contact  

Preferred method for ACCA ‘Chaplain Clips’ Email      Home 

Preferred Address:   Home      Work  

Are you an ACCA Certified Chaplain?   Yes   No   Previously   Want to Renew or Apply for Certification?    Yes   No  

Membership Category:                                Annual Dues

   Professional   $48.00   Full time vocational religious/faith-based correctional chaplaincy
  Retired Professional   $24.00 Retired from vocational correction chaplaincy
  Auxiliary/Contributing    $25.00 Any individual wishing to support ACCA in its work
  Associate    $24.00 Part-time, volunteers, students, interns in correctional ministry
  ACCA Certified    $36.00 ACCA Certified Clinical Correctional Chaplain w/in past 5 years
  Lifetime  $500.00 One time lifetime dues for all but Affiliate category
  Affiliate  $144.00 Organizations of good will with interest in correctional chaplaincy

If paying by check, please make checks payable to: ACCA

Mail to: Charles Williams, ACCA Treasurer
53 Ryan Road
Tolland, CT 06084

Remember that submitting the form does not create a membership ... be sure that you either use the PayPal option or mail your check today to our Membership Treasurer.