College of Texas Mediators
Individual
Affiliate Application
To apply for affiliation with CTM,
mail a completed application to the following address together with a
check made out to College of Texas Mediators to cover your annual dues:
College of Texas Mediators
5041 Trail Lake Drive, Fort Worth,
Texas 76133
Name:
Employer:
Preferred contact information: home/work (circle one)
Address:
Phone:
Cell:
Fax:
Email:
Completed 40-hour training:
When:
Where:
Trainer:
Address:
Phone:
Completed 24-hour Family
training:
When:
Where:
Trainer:
Address:
Phone:
Approximate number of cases mediated:
Other Occupation:
Name of any CTM Organization Affiliate which you are a member:
Signature:
Date: