MEOTA Group Membership Application

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Thank you for your interest in a group membership with MEOTA. Please fill out the form below and a member from our team will contact you shortly to finish the enrollment and set-up profiles for each individual member.

(3 person minimum - $42.50 OT; $38.25 OTA – practitioner only)

Name *

Email *

Address *

Home Phone

Mobile Phone *

Group Membership Type (3 person minimum - $42.50 OT; $38.25 OTA – practitioner only)

OTA

Clear selection

Names of members in group and email *

Practice area *

Name of employer *

Region *

North = Somerset, Piscataquis, Aroostook

Central = Penobscot, Washington, Hancock, Franklin, Waldo, Knox, Kennebec

South = Oxford, Lincoln, Androscoggin, Sagadahoc, Cumberland, York

Would you like an individual a or group invoice for membership payment? *

group

individual

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