2014 Membership Renewal

Complete the form below to renew your ATSA membership for 2014.

The form below requires a debit or credit card to complete your renewal. If you prefer to use a check or money order, or to submit an invoice to your employer, please download hard copy renewal forms instead of using the form below.

Contribution
Public Policy Donation (optional)
Please consider donating to help our Public Policy Efforts.
Read about the work your donation will support.
Select Other Amount above to remove the donation from your total

Use this field to donate an amount other than $35.00 to ATSA's Public Policy efforts.
Member Profile Update




PROFESSIONAL INFORMATION

If you select Other, enter your Other Job Function below.


  If you would like to list a mobile number that is only viewable by ATSA staff, include it here.
For ATSAlist listerve preferences, email your request directly to Mr. Aniss Benelmouffok at aniss@atsa.com. Please specify if you would prefer to receive individual postings, or the compilation "digest" version of the ATSAlist.



MAILING INFORMATION (private)


If analogous organizations and/or individuals involved in research endeavors request the ATSA mailing list, I consent to have my name, mailing address and/or email included on that list:
 (clear)



REFERRAL INFORMATION
Please indicate if you are available for referrals from the ATSA office:
 (clear)

The affiliation you choose below will be used when ATSA provides referrals.
(This information should match with the agency you indicated in the professional information section.)

(if not in list above)


  Enter any notes to include in your record here. (viewable by ATSA staff only)
Credit Card Information
Enter numbers only, no spaces or dashes.
Security Code Location on Credit Card
Usually the last 3-4 digits in the signature area on the back of the card.
 
Billing Name and Address
Enter the name as shown on your credit or debit card, and the billing address for this card.
Terms of Membership
  
  • I have not been charged with a felony during the last year.
  • I have not been accused, investigated, and/or involved in unprofessional or unethical conduct during the last year.
  • I have not been denied membership in or been terminated from a professional organization during the last year.
  • If any of the above statements are not true, I agree to fax or email information pertaining to the allegations and/or investigations from the past year to ATSA, within two weeks of submitting my renewal.
  • Any false, inaccurate or misleading information, including omissions provided on this form may result in my membership being denied or revoked.
  • I agree to support the objectives of the Association and to read and abide by the provisions of the ATSA Standards and Guidelines and Professional Code of Ethics, which may include having my name published in the Forum newsletter in the event of an ethical sanction against me by the ATSA ethics committee.
  • By checking the agreement box and submitting this form, I agree to the above noted statements and affirm that all of the information I am providing is accurate and complete.