Name:

Position:

Department:

Institution or Affiliation:

Address:

Home Address:

Telephone numbers: office

residence

fax

E-mail Address:

Send mail to: office address ______ home address ______ (check one)

Highest degree: _________ year: ________ granting institution: ______________________________

Area(s) of Specialization:

 

Area(s) of Competence:

 

Please return this completed form with a payment of $10.00 for students or $25.00 for faculty to:

James Kirk, Treasurer, NTPA
3915 County Rd 2526
Royse City, TX 75189

Or: click on the "make a donation" button below to pay online; you may then simply mail the completed form, bring it to the conference, or complete one at conference registration.

To be filled in by NTPA officer only:

Amount paid: $

Date of Payment: __/__/__

Form of payment: CASH CHECK

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04.11.07