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AKOTA Membership Application


MEMBERSHIP YEAR
is January 1 to December 31

For 2010:
OT/Associate:  $50.00
COTA:  $35.00
Student: $10.00
 Retiree Member: $100.00

Please complete the following information as you wish it to appear in the Membership Directory

 

*First Name:

Middle Initial:

*Last Name:

AK License #:

I wish to be listed in the Membership Directory
I would like to be on the AKOTA email list to receive updates, meeting changes, and board minutes

I prefer to be contacted at: 

 
Home
Work
Email Only

Home Information
*Address Line 1:  
Address Line 2:
*City:
*State:
*Zip/Postal Code:
*Home/Cell Phone:
Work Phone:
*Email:

Work Information
Place of Employment:
Business Address Line 1:
Business Address Line 2:
Business City:
Business State:
Business Zip:
Business Phone:
Director/Contact:
Business email:
Business Website:
Your Specialty:

Please check any of the boxes below that are relevant to your position
Administration/Management
Home and Community Health
Developmental Disabilities
Physical Disabilities
School System
Sensory Integration
Education
Technology
Gerontology
Work Programs
Mental Health
Private Practice
Hand Therapy
WFOT

How could AKOTA help you this year?
Continuing Education
Workshops
Legislative/Licensure Information
Contact with peers
Public awareness
Reimbursement
Exchange of ideas
Access to literature

Would you be willing to serve as a committee member, liaison, or any of the following?
Short term AKOTA project
Long term AKOTA project
Officer
Conference
Membership
Regional Contact
Archives
Grants
Awards
Newsletter
Public Relations
Liaison with another organization
Other Ideas

Alaska Voting District:

Additional comments, suggestions, etc., you have to make AKOTA work better for you:

PAYMENT DETAILS
*Membership Selection:  
*Payment Method: Check to be mailed
    Pay by Credit card
 

                                    

Mail Payment to:
Alaska Occupational Therapy Association
3705 Arctic Blvd. PMB 1616
Anchorage, AK 99503
For questions on this form, email akotapresident@akota.org

                                    

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