New Member Application
Maryland Athletic Trainers' Association
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APPLICANT INFORMATION
First Name *
Middle Name
Last Name *
NATA Status *
Date of Birth *
MM
/
DD
/
YYYY
Last Four Digits of SSN *
Address *
City *
State *
Zip *
Phone *
Email Address *
NATA Member Number
BOC Number
License Number
Professional Credentials
EMPLOYMENT INFORMATION
Current Employer *
Position *
How Long *
Address *
City *
State *
Zip *
County *
Phone *
Email *
Preferred Mailing Address *
MEMBERSHIP CATAGORY
Membership *
Please select from drop down:
MEMBERSHIP AGREEMENT
By entering my name and submitting the form, 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.
Your Full Name *
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