ILRTA Membership Application

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?:

INTEREST AREA AND SERVICE

Please check your area(s) of interest:

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

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

Or Call: ILRTA at: 708-687-4396

Join ILRTA