Mail completed application along with
check or money order made
payable to NJOTA TO:
NJOTA, PO Box 401, Summit, NJ
07902 1-888-80-NJOTA
Name:_________________________________ Employer:_____________________________________
*Preferred Mailing Work
Address:_________________________________
Address:_______________________________ _____________________________________________
______________________________________ Work Phone: (____)
_____________________________
Phone: (____)
__________________________ FAX:_________________________________________
County:_______________________________ E-Mail:________________________________________
*This address will be included in NJOTA membership database
______(Initial) I do not want my name and address
to be published in the NJOTA membership database
Membership dues: Please check appropriate category: _____
Renewal _____ New Member
** I was encouraged to join
by:___________________________________
____ OTR Membership $75.00 OTR Member. $140.00 2 Year OTR
Member
____ COTA Membership $50.00 COTA Member. $90.00 2 Year COTA
Member
____ Student Membership $25.00 FULL-TIME OT Student. List
School:_____________
____ Golden Membership $40.00 Circle: OTR/COTA over 62 yrs. Old
____ Auxiliary Membership $50.00 Member of another state OT
assoc. (include proof)
____ Associate Membership $50.00 Ineligible under any of the
above categories
____ NJOTA Contribution $_____ Supporting NJOTA in addition to
regular membership fees.
THIS
IS TAX DEDUCTIBLE.
TOTAL $_____
***Applicant is responsible for expenses incurred for checks
that are returned and membership will be held until payment is made.
I am interested in joining the following NJOTA
activities/committees:
__Practice __Legislation __Public
Relations __Education __Conference __Multi-cultural
__ADA __Newsletter __State Liaison __Awards __Membership __ Web
Master
__Presidential
Support __Reimbursement __Nominations __Fundraising __Other
Area of Practice: Check all that apply.
A__Administration/Management B__Traumatic Brain Injury C__School
System
D__Developmental Disabilities E__Education/Faculty F__Hand
Therapy
G__Gerontology/Long Term Care H__Home Health M__Mental
Health
P__Physical Disabilities Q__Pediatrics T__Technology
V__Private Practice/Consulting W__Work Hardening X__Other_____________
Specialty Certification(s):_________________________________
Please visit us on our website at www.NJOTA.org
