Status (check one):                  New Member                          

                                               Member (Renewal)                                                                                                                

Member Category Dues (check one):               Professional                  $95 ($80 to APT/$15 to SAZAPT)

                                                                        Affiliate                        $50 ($45 to APT/$5 to SAZAPT)

Name: First                                                                              Last                                                                              

Primary Credential:                                                                                                                                                     

Affiliation:                                                                                Job Title:                                                                       

Mailing Address:                                                                                                                                                          

City:                                                                                   State:                           Zip Code:                                       

Telephone:                                                                          Fax:                                                                                   

E-mail:                                                                                                                                                                         

Social Security Number:                                               -                                   -                                              

(Confidential – only used internally for verification of identities)

Make Check or Money Order Payable to APT

If paying by credit card:

        Visa

        MasterCard

Card Number:                                                                                                                              Expiration:                           

Signature:                                                                                                                                     Date:                                    

Send Completed Application to:

SAZAPT

P.O. Box 89981

Tucson, AZ 85752

Thank You!