HomeMy WebLinkAbout310951 05/02/17 aur 5,N'b
CITY OF CARMEL, INDIANA VENDOR: 371659
ONE CIVIC SQUARE NADTA CHECK AMOUNT: S""`""100.00*
�4 CARMEL, INDIANA 46032 SUIGTE AS INGTON AVE EXT CHECK NUMBER: 310951
«TtiN ALBANY NY 12203 CHECK DATE: 05/02/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1091 4341999 RENEWAL 100.00 OTHER PROFESSIONAL FE
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2017-2018 Membership/Registry Renewal FOR THE PERIOD: MAY 1, 2017 TO APRIL 30, 2018
Due by May 1, 2017
MAILING ADDRESS (Please Print) Renewing is easy when you do it online at NADTA.ORG!
NA E BIRTHDATE
c'Ac"VIMonth Date Year
COMPANY(ONLY if mail is to be delivered to a business address,or if you are an ORGANIZATION who is renewing) = New Membership
Renewal
ADDRESS (/,, Race/Ethnicity':
a3a, 1��V � I � � r�J ❑ Asian
❑ Black/African American
CITY STATE/PROVINCE ZIP/POSTAL CODE ❑ Hispanic/Latino/a
/ 'r7 ❑ Indigenous(First Nations/American
An
�5 � " ❑ dif n/Alaskan Native)
Inuit
COUNTRY EMAILM6tis
i/Vl�►+( Middle Eastern
❑ Native Hawaiian/Pacific Islander
J White/Caucasian
HOME PHONE CELL PHONE W K PHONE FAX ❑ Other
/// ,1 /� 'This demographic information provides NADTA with
�� /1 1 A a clearer picture of our oraanization's membership and
+++��'
*-�i i helps us identify the communities we may not be
ACKNOWLEDGEMENT NADTA turns away no one based upon economic
hardship.If you have special needs or extenuating
I have read, understand, and agree to abide by the newly revised NADTA Code of circumstances,please contact our office.
Ethical Principles posted on the NADTA website at: http://www.nadta.org/about- Alternative Training students are required to
nadta/code-of-ethics.html. I understand that membership and/or registry is contingent renew their membership through the duration
upon this signed acknowledgement,which will be kept on file at the NADTA office. of their program.
Failure to renew registry will void credentials.It is
X the responsibility of the RDT to renew by May 1 sr
each year.
SIGNATURE(Required for Registry and Me bership in NADTA) DATE
Check the box if you are interested in being a Description Fee Amount
mentor to new drama therapists ❑ Professional RDT/BCT or RDT/MT $120.00
(includes membership)
Save paper and postage! 0
Renew and pay online at www.nadta.org.
W Professional RDT(includes membership) $100.00 (OQ
Click on Membership and then on the renewal link. Organization/School $105.00
We also encourage you to login to update your online a Member $60.00
profile. _
Allied Professional $60.00
CHECK/MONEY ORDERS: All currency must be in U.S. m 65+Member(Proof of Age Required--Retired
g and no longer usingRDT credential $50.00
dollars. Make checks payable to: NADTA w
2 Renewing Alternative Training Student $40.00
Student $40.00
CHECK or MONEY ORDER NUMBER !case attach a ca of your student ID
CHAPTER DUES
There is a$25 fee if check is returned for insufficient funds.We ❑Tri-State New England $15.00
encourage Canadian and International members to use a ❑Socal ❑Quebec-changed from
credit card,as the bank charges we incur are substantial. Canadian Chapter
IX INTERNATIONAL POSTAGE FEE $15.00
Return this form to: NADTA = Outside U.S.,Canada,or Mexico
230 Washington Ave Ext.Suite 101 office@nadta.org O Alternative Training Fee(1xFee-Signed initial
Albany,NY 12203 518.463.8656 contract required) (1-year Alternative Training $80.00
Student Membership included
TOTAL PAYMENT AMOUNT: $ ` O Drama Therapy Fund Donation(Tax Deductible)
Late Fee(after June 1,2017) $20.00
CREDIT CARD (Please PRINT name as it appears on credit card.)
❑
Rr�� �g�T VISA/MASTERCARD
�� II �} D ❑AMERICAN EXPRESS
NAME ON CARD(Please Print) ,1 P R 2 8 2017
ADDRESS(Must match billing address in credit card profile.) CITY STATE/PROVINCE ZIPDE COUNTRY
B1:.
CREDIT CARD NUMBER EXP.DATE(MONTH/YEAR) SECURITY CODE
AUTHORIZED SIGNATURE DATE