MSOTA Membership Application Membership Year is April 01, 2010 - March 31, 2011. [Download Printable Membership Application]

PERSONAL INFORMATION First Name   * Required Field Last Name   * Required Field Address   * Required Field City   * Required Field State / Zip   - Please Select One - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory * Required Field   /   * Required Field County   * Required Field Telephone   () - * Required Field E-Mail   * Required Field   WORK INFORMATION Employer Name   Position/Title   Address   City   State / Zip   - Please Select One - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory   /   Telephone   () - FAX   () -   MEMBERSHIP INFORMATION Please enter all information. The selections you make will decide your registration level/fee.  * Membership Categories  OTR ($70) * Required Field COTA ($55) Student ($30): UMC HCC PRCC ICC Honorary/Retired (Free) (Select One)  Donate Categories   (above annual dues)  Magnolia ($50) Cotton ($25) Student Sponsor ($30): UMC HCC PRCC ICC (Select One) or None  Committee Interests  Recognition COTA Con't Ed Legislative/Licensure Nominations Newsletter/PR Special Interest Section Reimbursement None (Check Any/All)  Special Interest Sections  Geriatrics School Systems Home Health/Community Physical Dysfunction Education Mental Health Administration Developmental Disability Sensory Integration Technology Work Programs None (Check Any/All)  ** Would you be willing to present at an MSOTA continuing education session?  Yes No (Select One)  ** Would you agree to be listed in an MSOTA speaker's publication?  Yes No (Select One) ** If you answered Yes to either of these questions, an MSOTA representative will contact you with more information.

Your contact information will be listed in a directory provided to members. Your name and address will not be sold by MSOTA. Before clicking REGISTER, please review this form to assure all is correct. After clicking REGISTER, you will be prompted to pay your membership fee using Credit Card or PayPal.

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