Virginia Occupational Therapy Association

July 1, 2004-June 30, 2005 Membership Application

 

 

  •  OT Membership Dues (if your are not an OT Practitioner, please select Associate Member)

 $55.00

  • OTA Membership Dues

 $35.00

  • OT-Retired Membership Dues

 $32.50 

  • OTA - Retired Membership Dues

 $26.50

  • OT Aide Membership Dues

 $30.00

  • OT/OTA Student Membership Dues (*You are a student until you take the exam*)

 $25.00 

  • Associate Membership Dues (OT faculty, teacher, nurse, physical therapist, speech therapist, etc. whose interest in becoming a member is for the benefit of continued education, job opportunities, and promoting teamwork)

 $65.00

  • State Legislative Services Donation (optional) 

    (This is NOT a PAC campaign contribution)

 $
  • Scholarship Fund Donation (optional)
 $

  • Sustaining Member Contribution (optional)                                                                                                                          (bylaws state that the contribution should be at least 30% of your membership dues)

$
                                          Where do you work?                                                                                                                                                      

  ___ acute care            ___ home/community health               ___school system             ___ pediatrics                                                                         TOTAL

  ___ education             ___ mental health                                  ___ technology                 ___ rehab                                                                       (due by July 31, 2004)

  ___ gerontology        ___ work/ergonomic                              ___ hand therapy             ___ other

$

Name: _________________________________________   Address:_______________________________________________________________________________

City: ______________________________________  State: _________  Zip: _____________________    Home Phone: (  ____   )    _____     -       ______                   

Facility Name:_________________________________________  Facility Address:____________________________________________________________________

City: ______________________________________  State: __________  Zip: ____________________  Work Phone:(   ____   )     ____       -        ____          Ext.________    

Fax:______________________________________    Email Address: _____________________________________________________________________________

Credit Card Account Number__________________________________  Expiration Date________________                                                                                                                      (MasterCard, Visa, or Discover only)

Credit Card Holders Name_______________________________________________   Signature___________________________________________

Make checks payable to VOTA  *  2314-C Commerce Center Drive, Rockville, VA 23146

(804) 749-8001  *  FAX: (804) 749-8003  *  Website: www.vaota.org   *  Email: VaOTAssoc@aol.com

 

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How would you like to receive your 2004-2005 Membership Directory?

 

    ____ hard copy        ____ disk (Word 2000)    ____ Email (Word 2000)   ____ don't care for one

 

______________________________________________________________________________________________________________________

 

Referred by:                                                   __________               (If someone referred you to VOTA, list his or her name.  Anyone who refers 5 or more VOTA members within a member year will receive the next year's dues FREE! Person referred cannot have been a '03-'04 VOTA member.)

 

Membership dues payments and scholarship or legislative services donations are not deductible as charitable contributions for federal income tax purposes.

 

I MAY BE INTERESTED IN THE FOLLOWING

COMMITTEE(S):

                                ( ) Membership                     ( ) Scholarship/Awards                    ( ) Conference

                                ( ) Legislative                        ( ) Continuing Education                 ( ) Reimbursement

                                ( ) Public Affairs                    ( ) Finance                                    ( ) By-Laws

                                ( ) Fund Raising                     ( ) History                                     ( ) Nominations