Membership Application Form

Name *

First

Middle Name

Last *

Last

Credentials

Affiliation/Employer

If your membership is accepted, can we share the following information for website publication? *

Preferred Address for Website Publication

Preferred Phone for Website Publication

None, I don't want to share any contact information online (I understand that my name will still be listed)

Preferred Address for Website Publication

City

State/Province

Zip/Postal

Country

Preferred Phone Number for Website Publication

Email for Website Publication

Are you an MS Certified Specialist (MSCS)? *

Yes

Mailing Address

City

State/Province

Zip/Postal

Country

Phone

Email (this is also going to be your username)

Password *

Enter Password

Confirm Password *

Confirm Password

How did you find out about the International Organization of Multiple Sclerosis Rehabilitation Therapists (IOMSRT)?

Website Search

CMSC Annual Meeting

Another IOMSRT member

OtherOther

Check all that apply

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