NIATM Membership Form

NIATM Membership Form

Name_______________________

Home Address:

Street________________

City__________________ St______________ Zip____________

Home Phone_____________________

School Address:

School_________________________

Street_________________________

City___________________ St_____________ Zip____________

School Phone___________________

e-mail address _____________________

FAX ________________________________

Circle your preferred address Home School

May we release your name to vendors? Yes No

Are you a member of ICTM? Yes No Of NCTM? Yes No

NIATM dues for 1 year are $ 20.00 _____________