MATAMaryland Athletic TrainersMaryland Athletic Trainers Association

    Membership Application
 
MARYLAND ATHLETIC TRAINER'S ASSOCIATION
MEMBERSHIP APPLICATION
APPLICANT INFORMATION
First Name:   Middle:   Last Name:  
NATA Status:
select
 
Date of Birth:     Last 4 Digits of SSN:    
Address:  
City:   State:
select
 
Zip:  
Phone:   Fax: Email:  
NATA Member #: BOC #:   License #:
Professional Credentials:  
EMPLOYMENT INFORMATION
Current Employer:   Position:   How Long?  
Address:  
City:   State:
select
 
Zip:  
County:
select
 
Phone:   Fax: Email:  
PREFERRED MAILING ADDRESS
Preferred Mailing Address:    
MEMBERSHIP CATEGORY
Membership Category:
select
 
Anticipated graduation date (mm/dd/yyyy):     
MEMBERSHIP AGREEMENT
By submitting the form below, I acknowledge that the information I have provided is truthful and accurate. Dues paying members are the lifeblood of an organization. As such, I further understand that if at anytime I fail to maintain active membership I will lose access to the state website members section, and I will be removed from the state listserv and the Maryland Athletic Trainers’ Network.