MTIA MEMBERSHIP APPLICATION



mtia Membership Application

Special Offer for Emdat Platform Users

|Company Name       |Application Date       |

|Business Address       |

|City       |State/Province    |Zip/Postal Code       |

|Country       |Telephone       |Fax       |

|Web site       |

|Company Representatives to MTIA |

| |

|PRIMARY REPRESENTATIVE & VOTING |First Name       |MI   |Last Name       |

|MEMBER | | | |

|Account Management Privileges | | | |

|Title       |Email       |Tel:       |

|COMPANY REPRESENTATIVE |First Name       |MI   |Last Name       |

|Title       |Email       |Tel:       |

|EXECUTIVE/ADMIN ASSISTANT |First Name       |MI   |Last Name       |

|Account Management Privileges | | | |

|Title       |Email       |Tel:       |

|ACCOUNTING REPRESENTATIVE |First Name       |MI   |Last Name       |

|Title       |Email       |Tel:       |

|Company Profile (Optional) |

|Information will only be reported in aggregate for industry benchmarking and to deliver benefits that meet the needs of our Members. |

|Years in Business       |Number of Offices       |Total Number of Employees       |

|Primary Type of Business (Check one) |Total Revenue |How did you learn about MTIA? (Check one) |

|Medical Transcription Service Provider |$249,999 or less |MTIA Member       |

|Technology Developer/Provider |$250,000 - $499,999 |Internet Search |

|Educational Provider |$500,000 - $4,999,999 |Social Networking Site       |

|Medical Provider |$5,000,000 - $9,999,999 |Web Ad |

|Ancillary Service Provider |$10,000,000 or more |Industry Publication |

|Coding Provider | |Industry Convention/Tradeshow |

|EMR Provider | |Other       |

|Other       | | |

|Membership (Emdat Platform Users Special Rate – 30% off) |

|Membership is for one year from the date of application. MTIA membership dues and benefits are non-refundable and non-transferable. |

| Gold - $10,000 $7,000 | Silver - $5,000 $3,500 | Bronze - $2,000 $1,400 |

|METHOD OF PAYMENT Check Enclosed Credit Card |

| Visa | MasterCard | American Express | Discover |

|Card Number:       |Exp Date:       |CVC:       |

|Name on Card:       |Authorized Signature:       |

MTIA ( 4230 Kiernan Avenue, Suite 130 ( Modesto, CA 95356

Email: mtia@ ( Tel: 800-543-MTIA ( Fax: 209-527-9633

-----------------------

MTIA dues may be tax deductible as a business expense, not as a charitable contribution. US law requires businesses to report the lobbying portion of their trade association dues as an after tax expense. This is an estimated 2% of your MTIA dues.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download