Agency Membership Application

Director:		Agency:
Website:		Email:
Address:
City:		State/Zip:
Phone:		Fax:
Cell:		Home Phone:
Notes:

VOTING REPRESENTATIVE
In the event the agency director is unavailable or chooses to assign voting privileges to another person of the member organization, the director may appoint a Voting Representative. Please assign a Voting Representative by providing the following information.

Check here to appoint a Voting Representative

TRAINING REPRESENTATIVE
Please provide the name and contact information for the organization’s primary person responsible for training and staff development. This person will receive periodic correspondences regarding training opportunities available through ATA.

Check here to appoint a Training Representative

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