Name:

Company:

Address:

Phone:

City:

State/Zip:

E-Mail:

Fax:

Credentials:

Certificate type and number:

Active Member (active academy Member)

$35.00

Associate (non-active Academy Member)

$45.00

Affiliate (Cped, fitter etc.)

$45.00

Allied Health Professional

$45.00

This is to certify that I am a ABC (American Board for Certification) certified practitioner, and a member in good standing of the National Academy of Orthotists and Prosthetists.

(enter information only if you are a member of ABC)

Name:

Date(MM/DD/YYYY):

Total Membership Fees: