Texas Association of Orthotists/Prosthetists

Texas Association of Orthotists & Prosthetists
9211 West Road, Ste. 143-116
Houston, Texas 77064
(512) 266.8600 Telephone, (512) 266.8605 Fax

Please Complete the Entire Form and Click Submit when finished. A confirmation email should be sent to you with 24 hours of receipt.

YOU MUST BE AN ACTIVE MEMBER TO PAY DUES ONLINE.

If you are not a member, you MUST complete a Membership Application with your First Annual Dues and Application Fee.

PLEASE...DO NOT USE THIS FORM IF YOU ARE NOT AN ACTIVE MEMBER OF TAOP. THANK YOU.

First Name :
	First Name

Last Name :
	Last Name

* Credentials :

Company Name :
	Company Name

Street Address :
	Complete Street Address

City :
	City

State :
	State

Zip Code :
	Zip Code

Telephone Number with area code :
	Telephone Number w/area code

Fax Number with area code :
	Fax Number w/area code

Email Address :
	Email Address

* Annual Membership Dues :

	2009 Annual Membership Active (voting) Dues - $75.00
	2009 Annual Associate Member Dues (non voting)- $50.00

* Credit Card Type :

Credit Card Number :
	Credit Card Number

Expiration Date :
	Expiration Date - mm/yy

Zip Code Where Statements are mailed :
	Zip Code where cc statements are mailed

Street Address :
	Street Address where cc statements are mailed

3 Digit Security Code :
	3 Digit Security Code - on back of your card

Full Name as it appears on your credit card :
	Full Name as it appears on your credit card

Total Amount Submitted :
	Total Amount Submitted

* Authorization :

	Yes, I authorize this one time charge to my credit card
	No, I do not authorize this one time credit card charge