2007 Membership Application
Click here for a printable membership form.
Name
*
Address
*
City/State/Zip
*
E-mail Address:
*
Home Phone
*
Fax
County
Membership Type
*
Im a NEW member!
Im a RENEWING member!
Credentials
*
I am NOT NBCOT certified.
I am NBCOT certified as an OTR.
I am NBCOT certified as a COTA.
AOTA Membership
*
I am a current AOTA member.
I am not an AOTA member.
WOTA Districts
North Central
North East
North West
South Central
South East
South West
Work/School Name
Work/School Address
Work/School City/State/Zip
Work/School Phone
Work/School Fax
Practice Area
*
Special Interest Area
*
Administration
Birth to 3
Developmental Disabilities
Education
Geriatrics
Hands
Home Health
Mental Health
OT in Schools
Pediatrics
Physcial Disabilities
Private Practice
Sensory Integration
Technology
Work Programs
Other
Membership Fees
*
OT - $110
OTR - $110
OTA - $60
COTA - $60
OT Student - $18
OTA Student - $18
Associate Member - $30
Retired - $30
Life Member - $0
Contribution to WOTA Growth Fund
Contribution to WOTA Legal Fund
Contribution to WOTA Campaign Conduit
Payment Method
Visa
MasterCard
Name on Card
*
Billing Address
Billing City/State/Zip
Card #
*
Expiration Date
*
V-Code
*
*
Required
