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ARIZONA OCCUPATIONAL THERAPY ASSOCIATION MEMBERSHIP APPLICATION
July 1, 200__ - June 30, 200__
PLEASE
PRINT CLEARLY: Complete all lines
Renewal
New Member
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Name:
Date:
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Address:
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City:
State:
Zip:
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County:
Legislative District:
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Position/Title:
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Employer/School:
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Business Address:
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City:
State:
Zip:
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Home
Phone: (
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Business Phone: ( )
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e-mail address:
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AOTA
Membership
ID#:
Arizona OT License #:
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*May we publish your name, address,
e-mail & phone # in the Directory?
Yes No
*Published annually and
distributed to ArizOTA members.
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PLEASE CHECK
APPROPRIATE AREAS BELOW:
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Membership Fees: |
Area(s) of Practice: |
Committees: |
Member of AOTA
OTR
$60.00
COTA
$55.00
OTS/OTAS $40.00
Sustaining $80.00
Amount $______
Non-Member of AOTA
OTR
$65.00
COTA $60.00
OTS/OTAS $45.00
Sustaining $105.00
Associate $130.00
Amount $______
Other
Retired $40.00
Contribution to $_____
Legislative Fund
Amount
$______
Total Amount Due
$______
Credit Card Payment:
MC____ Visa____
#_____________________________
Exp. Date______________________
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Check all that apply
AA Administration
ED Education
GE Gerontology
HA Hand Rehab
HH Home Health
HOSP Hospital
INDUS Industrial Therapy
MH Mental Health
PD Phys. Disab./Rehab
PD/SNF Phys. Disab./SNF
PED Pediatrics
SP School Practice
Other _______________ |
Check if you are interested in
working on
committee
COTA Issues
Continuing Ed/Conference
Development of Districts
Finance/Ways and Means
Legislation and Regulation
Membership
Public Relations
Publications:
Newsletter/Reporters
Recognitions/Awards/
Nominations
Reimbursement
Research
Tucson Group
Please complete this form and return with
payment to ArizOTA.
Mail to:
ArizOTA Membership
P.O. Box 1531
Glendale, AZ 85311-1531
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