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Name: __________________________________________________________________
Address: ____________________________________________________________
City: ____________________________________________________________
State: ____________________________________________________________
Zip Code: ____________________________________________________________
Home Phone: ____________________________________________________________
Work Phone: ____________________________________________________________
NRTO Chapter: __________________________________________________________
__________ Basic
__________ Advanced
__________ Instructor I
__________ Instructor II
__________ Member--$25.00
__________ Retired Member--$15.00 To be eligible for retired membership, one must be age 65 or older or be receiving Social Security benefits.
__________ Supporting Institution--$30.00
__________ Additional Voluntary Contribution*
__________ Total Enclosed
A Membership List with Member Name, State of Residence, and Level of Remotivation Certification will be Published on the NRTO Web Page. Would you like your name and information to appear on this list (check one):
*Additional contributions will be used to fund current projects such as further web page development and further development of training materials. NRTO is a not-for-profit charitable organization that is incorporated in Massachusetts. Therefore, additional voluntary contributions are tax deductible. All those who contribute an additional voluntary contribution will receive a personal thank-you and have their name published as a “Supporter of Remotivation” in the Newsletter.
Please forward with your dues and donations to:
Michael Stotts, Executive Director
P.O. Box 440
York Harbor, ME 03911
Signature: ____________________________________________________________________
By signing above I agree to all the terms listed above including the applicable listings on the web page and newsletter.