Online Membership Application

Thank you for your participation in the Tennessee Association of Audiologists and Speech-Language Pathologists! Your membership will be in force for a one year period from the date of application. Your TAASLP dues support important programs which serve the public and the profession. Please supply the following information which will be used for the TAASLP membership email list, membership directory and database.

Name    License Number

Degree, Certification and/or licensure designation(s) following your name (choose one) Au.D., F-AAA Au.D., F-AAA, ABA AuD, CCC-A Ph.D, CCC-A Ph.D. M.A., CCC-A M.S., CCC-A Ph.D, CCC-SLP M.A., CCC-SLP M.S., CCC-SLP M.A.T., CCC-SLP M.Ed., CCC-SLP B.A., SLPA B.S., SLPA

Clinical Areas / Interventions you specialize in

Membership Designation (choose one):
Audiology
Speech Pathology
Student
Associate

Workplace

Employer/Affiliation

Setting Type (check all that apply)
Healthcare
School
Private Practice
University Clinic
Other (specify:)

Age groups you treat (check all that apply)
Birth to five
School age
Adolescents
Adults
Geriatrics

Business Address

Address, City, State, ZIP

Phone     Fax     *Business Email

Residence

Address

Address City State ZIP

Phone     *Personal Email

Which is your preferred postal mailing address?
Business
Residence

* A current email address is necessary for notification of the TAASLP newsletter and receipt of membership news alerts. We prefer to use your business email address for TAASLP/TAA related emailings.

Please indicate if you are a first-time (new) TAASLP Member, a renewing member, or a student conversion. (You must have been a student member of TAASLP, or other state organization (proof required), for the year prior to graduation to qualify for conversion rate.)
First-time (New) Member
Renewing Member  
Student Conversion

I am paying by:  Check   VISA   MasterCard  

Card Number:     Card Expiration Date (mm/yy):    
Cardholder Name or Organization Name:

Note: We only accept VISA and MasterCard at this time. We do not accept Discover or American Express.  You may also call in your credit card information rather than submitting it online. TAASLP contact information is provided at the end of this application. However, this IS a secure server form.

Would you like to become more active in TAASLP? We need you! Please indicate area(s) of interest where you would be willing to serve. Please indicate your order of preference by numbering the choices. Thank you!

Board Member
Convention
Membership
Continuing Education
School Affairs
Communications
Professional/Consumer Relations
Legislation
Political Action Committee (PAC)
Speakers Bureau (Topics: )

Comments or questions about your membership?

If you are calling or faxing in your credit card information,
do this as soon as possible after submitting your membership application.

Phone: 615-403-3994

If you are paying by check, submit your information, then mail the check promptly to:
TAASLP
P.O. Box 331307
Nashville, TN  37203-7513