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Join ILRTA

 

Member Information

Name:

Title:

Agency:

Agency Address:

City:

State: Zip:

County:

Work Phone:


Home Address:

City:

State: Zip:

County:

Home Phone:

Email Address:
Do you prefer to receive your mail at home or work?
CERTIFICATION

ATRA membership? Yes or No

Are you currently certified? Yes or No

If certified, by whom?:

Certification by: Date of Certification:

 

INTEREST AREA AND SERVICE

Please check your area(s) of interest:
Mental Health Substance Abuse Rehabilitation
Corrections Counseling Aging
Adolescents Community Development Disabled
Please check the way(s) you would be willing to serve ILRTA:
Committee Committee Chair
Board Member Writing articles for the Newsletter
Assisting with the ILRTA Conference Presenting at the ILRTA Conference
Office Use Only

Method of Payment:

( ) Check # __________________ ( ) Money Order ______________

Date Received: _______________ Amount Paid: ________________

Date Recorded:_______________

You may complete this form online and print it out. Send the completed form and payment ($40 professional or $15 student) to:

ILRTA
PO Box 587
Oak Forest, IL 60452

 

 


Contact ILRTA
contact us

For more information send inquiries to
ILRTA
PO Box 587
Oak Forest, IL 60452

Or Call: ILRTA at: 708-687-4396


 
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