1

NAMTPT Membership Renewal Application DATE: ______

Official use only

DATE received: ______

CHECK #: ______Amount: ______

Certificate Date: ______

Please print clearly and indicate (*) where mailings should be addressed. (will be sent to home address if not indicated)

Name and Professional Title(s): ______

Business Information: (required, this will be listed on the website as contact information)

Business name: ______

Office Address: ______

City: ______State: _____ Zip: ______Phone: ______

Fax: ______

Website: ______Email: ______

* let me know if any part of this needs to be hidden from the public (working out of home etc)

Home Address: (required, this is not visible to the public)

Address: ______City: ______

State: ______Zip: ______Phone: ______Email: ______

____ CHECK IF ANY OF THIS INFORMATION NEEDS TO BE CHANGED ON THE WEBSITE (AND YOU CAN NOT DO IT YOURSELF)

***indicate address to mail important news, certificate and journal to.

Membership category:

_____ Professional ($175.00/year) Myofascial Trigger Point Therapists who are: NCMTPT – Certified by the Certification Board for Myofascial Trigger Point Therapists OR MTPT – graduate from a listed training program OR grandfathered school graduate (complete FULL program) AND Fulfillment of continuing education each membership year of 20 CEU’s

CBMTPT Board Certification # ______Expires: ______

Or ______CMTPT – Graduated from ______

ANDcompleted 20 hours CEU per membership year (REQUIRED) (you may be audited at any time)

____ Associate Professional ($175.00/year)Myofascial Trigger Point Therapists who are: CMTPT – Certified by the Certification Board for Myofascial Trigger Point Therapists OR MTPT – graduate from a listed training program OR grandfathered school graduate (complete FULL program)

______Associate Professional - Allied ($175.00/year)All other licensed allied healthcare professionals who have studied Myofascial Trigger Point Therapy may include MD, DC, OT, PT, Nurse, Massage Therapist, other bodyworkers, etc.

_____ Student ($55/Year) Currently attending a listed school or training program in Myofascial Trigger Point Therapy

(no listing or subscription to Journal of Bodywork and Movement Therapies)

___ Supporting/ — $55/year Friend of NAMTPT patients, organizations, supportive professional etc

$10 discount for conventions, (no listing or subscription to JBMT)

___ NAMTPT Contribution $______thank you!

Mary Jo Smiley CMTPT membership chair 608 Pike Dr Cranberry Twp PA 16066

Call with any questions or concerns 724-494-1468 10AM to 12midnight eastern time

Professional Members: (required)

I attest that I have fulfilled 20 CEUs in the past 12 months. I understand that I may be audited by the NAMTPT at any time and must show proof of continuing education.

Legal signature ______

Print name______Date______

All Members:

By my signature below, I understand that upon acceptance as an NAMTPT member, all fees paid by me to NAMTPT are non-refundable. I have completed the NAMTPT membership application accurately and honestly. I understand that NAMTPT members are required to maintain the highest standards of professional conduct and strictly adhere to the NAMTPT Code of Ethics. I understand that violation of the Bylaws and/or Code of Ethics can be grounds for termination of any membership. I attest that I have never had a permit or license related to my practice as a health care professional revoked, suspended, or voluntarily surrendered. I have never been the subject of any complaint or investigation regarding a sexual act, conduct, molestation and/or assault whatsoever.

Legal signature______

Print name______Date______

Please indicate level of membership on the first page and enclose a check or money order made payable to:

National Association of Myofascial Trigger Point Therapists or NAMTPT

Mail to

Mary Jo Smiley CMTPT membership chair 608 Pike Dr Cranberry Twp PA 16066

Call with any questions or concerns 724-494-1468 10AM to 12 midnight eastern time

Thank you for your membership!

We welcome and encourage your input and want to hear from you!

NAMTPT offices and committees need your help to run smoothly, please contribute to the newsletter. There is an unofficial email group, contact Mary Jo at if you are not on it.

All of this form can be completed online. Please renew on line if you can, there is no need to fill this form out if you have renewed online. You can simply send a check with your name in on the check.

Please call Mary Jo Smiley if you do not understand how to renew on line, I am glad to help you.