South Dakota Occupational Therapy Association

New Member and Renewal Application

***All new and current SDOTA members please fill out this form.***

Annual membership dues are collected each July and coincide with the fiscal year (July 1 - June 30). A SDOTA directory is available for membership. Please enter all information as you'd like it to appear in the SDOTA Directory.
Please enter all information as you would like it to appear in the SDOTA Directory.

Name: Credentials:

If student: School: Graduation Date:

Address:

Legislative District:

Home Phone:		Work Phone:
FAX:		Email Address:

Workplace:

Address:
	Zip:

Work Area/Specialty Area/Qualifications:

Membership in Professional Organizations:

Committees: I am interested in participating in one of the following committees: (please check)

Standing Committees:
Public Relations
Continuing Education
Newsletter
Membership
Awards/Recognitions
Reimbursement
Government Relations
Student Committee
Bylaws Policies & Procedures
Fund Development

AD HOC Committees: Please call SDOTA for current opportunities.

Other:
COTA Issues
Short term tasks

MEMBERSHIP STATUS FOR WHICH YOU ARE APPLYING
   New Member
   Renewal

    * Refer to initial date of application

Fifty two percent of SDOTA membership fees go to pay for the lobbyist and is not tax deductible.