Mobile Area Physical Therapy Organization We serve the Physical Therapy profession 2005 MAPTO Membership Application MAPTO is not funded by the APTA or the Alabama PT Association. Annual dues have not increased since the organization began over 20 years ago, and are used to support local exchange of information and CEU opportunities. Name:____________________Circle one: PT /PTA / SPT / SPTA Home Address:___________________________________ Home Phone:_________________ Employer /Addr:______________________________________ Work Phone:_________________ Email:______________________ Fax: _______________________ Dues (for January - December) circle one: PT ($20.00) PTA ($15.00) Student (free) Communication by email and the MAPTO website saves the organization money. Check one: ____Please send my notices including a link to the website by email. I do check regularly. ____ Please send my notices and newsletters by mail. I do not have or do not check email. Which MAPTO committees would you be willing to work with? ____ Social ____ Membership ____ Nominating ____ Legislative ____ Program Make checks payable to MAPTO and mail to: Stjani Fridriksson MAPTO Secretary, c/o Grelot Physical Therapy, 5920 Grelot Rd, Bldg H, Ste B, Mobile, AL 36695