Georgia Athletic Trainers Association

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GEORGIA ATHLETIC TRAINERS ASSOCIATION

Membership Application/Renewal

(January 1 - December 31 )

Membership dues are paid on a calendar year basis renewed each January. To be maintained as an active member, dues must be paid by March 31 or members will no longer receive GATA newsletters or other correspondence. If you have a paid your dues as a certified, associate, or student member of the NATA, your annual dues for GATA were collected with your NATA dues.  Please verify that your mailing address is correct and reflects a Georgia address.

First Name:____________________________________________ Last Name:___________________________

Employer: _________________________________________________________________________________
Work Address: _____________________________________________________________________________
City:_____________________________________________ State:___________ Zip:______________________
Work Phone:___________________________________ Work Fax :_____________________________________

Home Address:______________________________________________________________________________
City:_____________________________________________ State:___________ Zip:______________________
Home Phone:___________________________________ Home Fax: ____________________________________

Email Address:_____________________________________________________________
Preferred Address for GATA Correspondence? 	____Home 		____Work
NATA Member #:____________________                NATABOC Certification #:_________________
GA Board of Athletic Trainers State License #:____________________

q I wish to contribute $______ to the Lobbying Fund. I have increased the total enclosed by this amount.

q I do not wish to contribute to the Lobbying Fund. I have enclosed the appropriate dues amount only.

Total Amount Enclosed $______

Please make checks payable to: GATA, Inc. and return your completed application to: