Membership Application

Name                          _________________________________________________

       (last)                        (first)                        (MI)

Address                      _________________________________________________

                                                                         (street)

                                  _________________________________________________         

                                           (city)                       (state)                       (zip code)

School/ Affiliation         ________________________________________________

Home Phone               _________________________________________________

                                     (area code)                                       (number)

 Work Phone               _________________________________________________

                                     (area code)                                       (number)

 FAX                           _________________________________________________

                                     (area code)                                       (number)

E-mail                         _________________________________________________

              Please print, fill it out, and return this statement with your check payable to OSTA  and send to: 

P.O. Box 80456 Portland, OR 97280-1456

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