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Membership Application
MARYLAND ATHLETIC TRAINER'S ASSOCIATION
MEMBERSHIP APPLICATION
APPLICANT INFORMATION
First Name:
Middle:
Last Name:
NATA Status:
select
Member
Non-Member
Date of Birth:
Last 4 Digits of SSN:
Address:
City:
State:
select
None Selected
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Minor Outlying Islands
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Phone:
Fax:
Email:
NATA Member #:
BOC #:
License #:
Professional Credentials:
EMPLOYMENT INFORMATION
Current Employer:
Position:
How Long?
Address:
City:
State:
select
None Selected
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Minor Outlying Islands
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
County:
select
None Selected
Allegany
Anne Arundel
Baltimore
Calvert
Caroline
Carroll
Cecil
Charles
Dorchester
Frederick
Garrett
Harford
Howard
Kent
Montgomery
Prince George's
Queen Anne's
St. Mary's
Somerset
Talbot
Washington
Wicomico
Worcester
Phone:
Fax:
Email:
PREFERRED MAILING ADDRESS
Preferred Mailing Address:
Home
Work
MEMBERSHIP CATEGORY
Membership Category:
select
None Selected
Student $20
Associate $40
Certified Student $30
Certified $40
Retired $0
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.
I authorize the verification of the information provided on this form.