Celtic Chicago, Inc.

First Name *
Middle Name
Last Name *
Professional Degree(s)

Designations include MD, PhD, PsyD
Office/Primary Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Office/Primary Phone Number *
Email *
Membership *
Early Career Professional - $95 (USD)
Current Licensure Status *
License Provisional License Work in Exempt Setting Other
If Licensure is exempt or other, please provide further information of where and/or why. *
Have any previous questions ever been raised about your professional ethics? If so, please explain fully.
All appropriate attachments must be submitted with the completed online application at the same time. Please use the browse button below to locate your document on your computer for uploading. Allowed file types: Portable Document Format (PDF), Microsoft Word Document (DOC) or Rich Text Format (RTF). All documents must be PC Compatible and have a file extension of one of the allowed file types.
Letters verifying clinical/research supervision and current academic training program status can be from the same person if applicable. Please refer to the SSTAR website for additional information on qualifications for membership.
Current CV *

Please attach a copy of current Curriculum Vitae.
Diploma
If applicable, documentation to support licensure status checked above.
Additional information you wish to provide or highlight about your qualifications.
Please enter your full name to certify that the information provided is accurate. *
All questions should be directed to the SSTAR Officel at info@sstarnet.org or at 847.647.8832.
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