Member Information
Name:
Title:
Agency:
Agency Address:
City:
County:
Work Phone:
Home Address:
Home Phone:
ATRA membership? Yes or No
Are you currently certified? Yes or No
If certified, by whom?:
INTEREST AREA AND SERVICE
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 ($30 professional or $15 student) to:
ILRTA Sr. Sandi Salois 2224 Oneida St. Apt. 206 Joliet, IL 60435 (847) 692-4956
About ILRTA ILRTA Leadership Membership Information Membership Application