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KY Licensure
2008 Online Membership Application
Membership is valid for 12 months from date of application.
PERSONAL INFORMATION
Last Name:
First Name:
Middle Initial:
Credentials:
Primary area of Practice:
HOME / MAILING ADDRESS
Street:
City:
State:
Zip:
County:
EMPLOYER / SCHOOL ADDRESS
Name:
Street:
City:
State:
Zip:
OTHER CONTACT INFORMATION
Home Phone:
Work Phone:
E-Mail Address:
*Providing e-mail addresses assures the member of the latest updates and decreases KOTA's operating costs.
DISTRICTS
(include preference or office will assign by home address)
CENTRAL (includes Bardstown, Elizabethtown, Louisville, Versailles)
EASTERN (includes Corbin, Lexington, Richmond, Pikeville, Winchester)
NORTHERN (includes Ashland, Covington, Maysville, Morehead, Paris)
WESTERN (includes Bowling Green, Madisonville, Owensboro, Paducah)
KY OT License?
Yes
No
AOTA Member?
Yes
No
Would you like to receive your KOTA newsletter via e-mail?
Yes
No
What courses would you like to see KOTA sponsor for continuing education?
CHOOSE A MEMBERSHIP TYPE
Sustaining ($80.00) - OT or OTA providing additional support to KOTA
OT ($60.00) - Occupational Therapist or Sustaining OTA
OTA ($40.00) - Occupational Therapy Assistant
Student ($20.00) - Currently enrolled in OT or OTA program
Associate ($30.00) - OT/OTA member of other state organization, OR non-OT
Organizational ($80.00) - Agencies or institutions supporting OT
SERVICE OPPORTUNITIES
I would like to help with:
District Activities
Education
Legislative Affairs
Finance
Membership
Newsletter
Practice
Programs / Conference
Public Relations
Nominations
Ways & Means
PAYMENT INFORMATION
(
MasterCard or Visa only accepted
)
Cardholder Name:
Card Number:
Expiration Date (month/year):
Card Billing Address:
I wish to provide additional financial support to
KOTA's General Fund in the amount of: $
Receipt and membership card will be mailed to your home address; please allow 3-4 weeks for processing. The membership directory is listed in its entirety on KOTA's website. If you would like a hard copy, please contact the office manager.
