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.