NATA 2009 Online Membership Application

2009 Membership Form

Please complete the application in full and press the SUBMIT button at the bottom of this form. Please allow up to 72 hours for processing.
PERSONAL INFORMATION
Prefix
First	Middle (name or initial)	Last	Maiden
Last 4 Digits SSN#	Date of Birth (mm/dd/yyyy)	Employer

Your preferred mailing address determines your district affiliation and is where you will receive your NATA mail. My preferred mailing address is my work home:
Street Address	City		State			Zip
Country	Int'l Country Code (if applicable)				E-mail Address (must include to receive receipt of your payment)
Work Phone (10 digit)	Cell Phone (10 digit)			Home Phone (10 digit)			Fax (10 digit)

Date of Certification (mm/dd/yyyy)		BOC Certification #

Have you been a member of NATA previously? Yes No
Previous Member #

Did another NATA member refer you? If so, who?

MEMBERSHIP CATEGORY
(please refer to the Dues Structure portion of this form)
(please refer to the Membership Categories & Policies)

Regular Certified	Associate
Undergraduate Student (non-certified)	International (non-certified)
Graduate Student (non-certified)	International (certified)
Certified Student, anticipated grad date mm/dd/yyyy format:
I am an international student currently studying in the US.

GENDER

Female

Male

ETHNICITY (optional)

American Indian/ Alaskan Native	Hispanic
Asian or Pacific Islander	White (not of Hispanic Origin)
Black (not of Hispanic Origin)	Multi-Ethnic
Other, please specify
*In accordance with Federally-designated categories

HIGHEST LEVEL OF EDUCATION

Doctorate		Physician		Masters
	PhD		MD		MS
	EdD		DO		MA
	HSD		Other (specify)		MEd
	DPE		Other (specify)		MPT
	JD				MBA
	DPT				Other (specify below)
	DC
	Other (specify)
Bachelors			Two Year Degree		Not Degreed

Undergraduate School:	Graduation Date:
Graduate School 1:	Graduation Date:
Graduate School 2:	Graduation Date:

PROFESSIONAL CREDENTIALS
(check all that apply)

	CAT (C) (CATA)		Orthopedic Technician
	Certified Cardiographic Technician		Personal Trainer
	Chiropractor		PES (NASM)
	CSCS (NSCA)		Physician
	EMT/EMT-P		Physician Asst
	FACSM		PT
	Massage Therapist		PTA
	Nurse (RN, LPN)		Teaching Certificate (please specify):
	Occupational Therapist		Other (please specify):
	Occupational Therapy Assistant		No Professional Credential

Do you have an NPI number? Yes No

For more information visit: https://nppes.cms.hhs.gov

I wish to be considered for a committee or other volunteer position. Yes No

For committee/volunteer work please indicate areas of interest or expertise:

Please answer, under oath and penalty of disqualification: Have you ever been convicted of a felony? Yes No

My employer pays my NATA membership dues.

2009 DUES STRUCTURE
Members are billed the first week of November for the following calendar year. Dues include membership in the national, district and state associations.

		Dues are prorated based on date application is received by NATA.
		Jan 1- Dec 31		May 1-Dec 31		Sept 1- Dec 31
District	State or Providence	Professional	Students	Professional	Students	Professional	Students
1	CT, MA, ME, NH, RI, VT, Quebec, New Brunswick, Nova Scotia	$200.00	$85.00	$150.00	$65.00	$100.00	$45.00
2	DE, NJ, NY, PA	$205.00	$85.00	$155.00	$65.00	$105.00	$45.00
3	MD, NC, SC, VA, WV, Dist of Col.	$193.00	$73.00	$143.00	$53.00	$93.00	$33.00
4	IL, IN, MI, MN, OH, WI, Manitoba, Ontario	$205.00	$75.00	$155.00	$55.00	$105.00	$35.00
5	IA, KS, MO, ND, NE, OK, SD	$210.00	$80.00	$160.00	$60.00	$110.00	$40.00
6	AR, TX	$240.00	$75.00	$190.00	$55.00	$140.00	$35.00
7	AZ, CO, NM, UT, WY	$220.00	$105.00	$170.00	$85.00	$120.00	$65.00
8	CA, NV, HI, Guam	$195.00	$105.00	$145.00	$85.00	$95.00	$65.00
9	AL, FL, GA, KY, LA, MS, TN, Puerto Rico, Virgin Islands	$202.00	$80.00	$152.00	$60.00	$102.00	$40.00
10	AK, ID, MT, OR, WA, Alberta, British Columbia, Saskatchewan	$180.00	$70.00	$130.00	$50.00	$80.00	$30.00
	International (Journal of Athletic Training and NATA News online only)	$150.00	$150.00	$100.00	$100.00	$50.00	$50.00

FOR NON-CERTIFIED STUDENTS ONLY

Note: Non-certified students may purchase a print subscription to the Journal of Athletic Training to supplement the online copy.

12-month subscription to the Journal of Athletic Training (non-refundable): $20.00

PAYMENT OPTIONS

Please choose only one payment option. (Credit Card or Automatic Bank Transfer)

Payments must be in U.S. Dollars
Automatic Bank Draft Transfers MUST be drawn on a U.S. Bank
Total Dues must include National Dues and District Dues

Name as it appears on account:

Address as it appears on account:

City:

State:

Zip:

I authorize NATA to deduct $ from my checking/savings account.

Bank Name:

Type of account: CHECKING SAVINGS

ABA/ROUTING#:

ACCOUNT#:

MasterCard

VISA

American Express

Account Number: Expiration Date (use mm/yyyy format):

Full Name (as it appears on credit card):

I authorize NATA to charge $ to my credit card.

COMMUNICATION PREFERENCES

		I DO NOT wish to receive surveys by email.
		I DO NOT wish to receive information on athletic training products and services, discounts and special offers by email.
		The quarterly Journal of Athletic Training is available online to all members. Certified and associate members may request a printed copy. Please help us manage the escalating printing and postage cost by requesting a hard copy only if you read the Journal regularly and access to the online version is not sufficient for your needs. Thank you.
		Certified and Associate members, check this box to receive the quarterly Journal by mail. (This flag is reset annually.)
		You may print your own membership card from the Member Services section of the NATA web site. If you also need to receive a membership card from NATA, please check this box.

By submitting this form using the button below, you adhere to the following statements:

By submitting this form, I pledge to abide by NATA's bylaws, policies and procedures, membership standards, code of ethics, and other rules and regulations. Click here to view these documents online. I understand violations may subject me to disciplinary action as outlined in the Membership Standards.
Credit Card or Bank Draft Disclaimer. I authorize NATA to charge my credit card or checking/savings account. If I close this account prior to this indebtedness being satisfied, I will notify NATA’s membership department of the specifics of my new account or how the outstanding balance will be paid. I understand that if I fail to meet my payment obligation to NATA, my membership will lapse.
Payments or contributions to the National Athletic Trainers' Association are not deductible as charitable contributions for federal income tax purposes. Payments may be deducted as a business expense. If in doubt, please consult your tax advisor. NATA will not discriminate against any individual on the basis of religion, sex, ethnic background, or physical handicap. 13.27% of dues are allocated for lobbying.