ATSNJ Membership Application

Previous ATSNJ Member

Yes

Title

First

Middle

Last

Suffix

Credentials

Home Address

Home Address 2

Home City/Town

Home State/Province

Home ZIP/Postal Code

Preferred Phone Number

Preferred Email Address

Are you a student?

Yes

What school do you attend?

Employer

What is your primary employment setting?

What COPA setting are you employed in?

If other:

Work Address

Work Address 2

Work City/Town

Work State/Province

Work ZIP/Postal Code

What is your preferred mailing address?

Home

Work

Which ATSNJ region to do you live in?

Do you have an NATA number?

Yes

NATA Membership Number

What is your designated ATSNJ membership category?

Certified/Licensed ($65)

All BOC Certified or NJ Licensed Professionals, including out-of-staters that are licensed in NJ

Associate/Other ($50)

Student ($25)

Retired/Non-Practicing ($0)

What state are you licensed in?

New Jersey

Other

I'm licensed in more than one state

I'm not licensed

What other state are you licensed in?

Which states do you currently hold licensure in?

License Number

Additional License Number

Do you have an NPI number?

Yes

NPI Number

Do you have a BOC number?

Yes

BOC Number

Signature

I hereby apply for membership in the Athletic Trainers' Society of New Jersey, Inc. If accepted as a member of this organization, it is my desire to advance its interests and ideals to the best of my ability and to abide by its Constitution and Bylaws.

Date

ATSNJ Membership Application

Contact Info

ATSNJ, Inc.

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