SCCMHCA Membership Application

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Professional License/ Certification(s) You Currently Hold
Have you been convicted, pled guilty, or pled nolo contendere for violation of any federal, state, or local law, or do you have charges pending (other than a minor traffic violation)?
Have you had an investigation, formal complaint, disciplinary action or consent order filed against you?
Have you developed any disease or condition, physical, mental or emotional, including alcohol or other substance abuse, that might interfere with your ability to competently and safely perform the essential functions involved in your profession?
Have you had your license disciplined by any state?
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I hereby swear/affirm that I have read all questions on this Membership Application and have answered truthfully, accurately, and completely. For licensed professionals only: I affirm that my license is in good standing as of the signing of this application. NOTE: For those who have a disciplinary action of record, you may send in your application to the SCCMHCA Board for consideration with your letter of explanation. I further affirm that I have read and agree to abide by SCCMHCA ByLaws and Code of Ethics, posted on their website at www.sccmhca.org

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