MTIA Membership Application

Please refer to the Vision 20/20 page to determine the category of membership that is most appropriate for you or your company. Each Gold, Silver and Bronze member must designate at least one primary voting company representative. The primary company representative also will receive the MTIA e-newsletter, subscription to Health Data Matrix, and other announcements. The primary representative may be changed at any time by notifying the MTIA office by phone, fax, or e-mail.

A downloadable application is available here.

Choose one:	I am a current MTIA member I was a MTIA member previously I have never been a MTIA member.
Company:
Business Address:
City:
State/Province:
Zip/Postal Code:
Country (required if no postal code):
Phone:
Fax:
Website:
Company Representatives to MTIA
Primary Representative & Voting Member
First Name:
Last Name:
Title:
Email:
Telephone:
Company Representative
First Name:
Last Name:
Title:
Email:
Telephone:
Executive/Administrative Assistant
First Name:
Last Name:
Title:
Email:
Telephone:
Accounting Representative
First Name:
Last Name:
Title:
Email:
Telephone:
Company Profile Years in Business Number of Offices Total Number of Employees Type of Business (Check all that apply) Medical Transcription Service Provider Technology Developer/Provider Educational Facility Medical Provider Ancillary Service Provider Coding Provider EMR Provider Other: Total Revenue $499,000 or less $500,000 - $4,999,000 $5,000,000 - $9,999,000 $10,000,000 or more How did you learn about MTIA? (Check all that apply) MTIA Member: Internet Search Social Networking Site Web Ad Industry Publication Industry Convention/Tradeshow Other:
Membership Type
Please select one of the following annual membership types that best suits you. For more information on membership types, please see the Vision 20/20 page.
Please select a member type... GOLD $10,000 SILVER $5,000 BRONZE $2,000
Payment Information
Please select a payment plan: Full Amount Bi-annual (two payments: one now and a second in six months) Quarterly (four payments: one now and then every 90 days)
Total Amount of Membership Order: $ Amount to be charged now: $
Card Type:
Cardholder name (as it appears on card):
Card number:
Card Expires:	Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 2010 2011 2012 2013 2014 2015 2016