Local Association Application

Person Completing This Form:
Contact Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
E-mail*
Phone Number*

Area CodePhone Number
State of Affiliation*
Local Association Information:
Name of Local Association*
Officer 1 Name*
Officer 1 Position*
Officer 2 Name*
Officer 2 Position*
Will MTNA be collecting your Local Association Dues?*

Yes (If yes, please fill out membership type, Dues Amount and who should receive Dues Rebate Checks below)No (If no, proceed to next section)
Type of Membership

General (Active)Collegiate (Student)Senior
Dues Amount
Senior Dues Policy (age requirement and/or length of membership requirement)
Person receiving dues rebate check from MTNA. Name:
Person receiving rebate check from MTNA. Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Local Association Documents:
Upload Minutes (Word or PDF document)*
Upload Bylaws (Word or PDF document)*
Upload list of current MTNA members joining chapter (Word or PDF document)*
Upload signed FTC Certification Form
Should be Empty:

Local Association Information: