AROTA Membership Application

AROTA Membership Application

May 17, 2012

Applicant Information

First Name *	Middle Name/Initial	Last Name *

Membership Information

New Membership

Renewal

OTR/COTA License Number	AROTA Member Number	Expiration Date

Applicant Home Information

Address *


City *	State *	ZipCode *


Phone *		Email *

Applicant Work Information

Address *


City *	State *	ZipCode *


Phone *	FAX	Email

Information Disclosure

Which information would you like to be included in the online membership directory?

Home

Work

None

Education

Please enter your Degree(s), University and Year Earned, one per line.

Certification

Please enter your Certification(s) and Year Certified, one per line.

Please check your primary areas of practice

Acute Care	Community Re-entry	Education	Ergonomics
Hands	Home Health	Inpatient Hospital	Mental Health
Pre-school Settings	Private Practice	Outpatient	Orthopedics
Rehabilitation	Residential	Schools	Skilled Nursing Facilities
List the current age group of clients servicing:

Positions are open and we need your help to be advocates for our profession and better serve our members. Check the committee(s) you are interested in serving on:

Awards/Scholarship	Bylaws	COTA Forum	Cont. Education
Ethics	Finance	Legislation	Licensure
Medicaid	Medicare	Membership	Public Relations
Research	Online News Journal
Are you interested in serving as a chairperson on a committee?			Yes No

Check any executive board position you are interested in running for:

AOTA Representative	AOTA Alternate Representative	District Chair
Nominations	President	President-Elect
Secretary	Treasurer	Vice President

Membership Type

To qualify for the new practitioner rate, you must have received your license no more than 12 months prior to the date you apply for membership.

OTR $60	OTR $30 (new practitioner)*
COTA $40	COTA $40 (new practitioner)*
Retired $20	Student $10
Associate $60

Membership must be renewed yearly. Renewal notices are sent at the beginning of the quarter in which your membership is set to expire.

This is step one of the application process. Upon clicking the Submit Application & Proceed to Checkout button you will be redirected to a PayPal Shopping Cart where you can make your payment. Your application is contingent upon successfully making your payment. If you do not complete the checkout process, you will have to re-apply. Please contact AROTA if you have not received your membership card within 30 days of submitting your membership dues.

by CaduceusWebs