EmailMe Form - OTARA Contributor Application

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Form Type *

Payment Type *

Contributor Type

First Name *

Middle Initial

Last Name *

Department/Company *

Position/Title *

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Primary Phone *

### - ### - ####

Secondary Phone

### - ### - ####

Fax

### - ### - ####

Email *

Preferred Contact Method

Highest Level of Education

ACTAR Number (If none type "N/A"

List certificates with dates of training

Resume Upload

All applicants must complete resume submission. Accepted file types: .pdf .doc .docx .tif

How did you learn about us

Additional comments or questions

Shirt Size

Payment Amount

I have read and will adhere to the Constitution and By-Laws *

Yes

No

I hereby apply for contributorship in the Ohio Traffic Accident Reconstruction Association. I state that all of the aforementioned data is true and correct to the best of my knowledge. I understand that discovery of any false information will be grounds for revocation. I understand that the application processing fee is nonrefundable. I also realize that there is no guarantee that I will be accepted by this organization, that verification may be required, and that I will comply with the Code of Ethics and Bylaws of the Ohio Traffic Accident Reconstruction Association (OTARA). Furthermore, I will send my personal resume (if not an ACTAR applicant) and application fee, and yearly dues after submitting my online application to become a member to OTARA. I authorize investigation of all statements contained herein and references listed above to give you any and all information and pertinent facts that may be, personal or otherwise, and release all parties from liability or damage that may result from furnishing same to you. I agree to electronically transfer or mail my check/money order in the correct amount as indicated above.