------------------------------------------------------------------------------------------------------------ APPLICATION FORM FOR BAITIS MEMBERSHIP Please complete the application form and use the ‘submit’ button to send us your application. You will be contacted upon acceptance of your application. At that time, you will be offered the option of paying the membership fee through PayPal or by check. First Name of Applicant Surname of Applicant Postal Address City Zip / Postal Code State, Province or Region Country Telephone Fax (Optional) Cell Phone (Optional) E-mail Address Membership Requested Affiliate Membership Professional Membership Instructor who trained you Date Trained (the year is sufficient) AIT Device/s Used Years Practicing Berard AIT Not Applicable 0 - 3 years 3 - 6 years 6 - 10 years 10 - 15 years More than 15 years College Degree Doctoral Level Graduate Level Undergraduate Level Field of Study Please Select Occupational Therapy Speech/Language Special Education Psychology Medicine Audiology Physical Therapy Health/Wellness Music Therapy Optometry Other Current Occupation Please Select Occupational Therapist Speech/Language Therapist Special Educator Psychologist Medical Doctor Audiologist Physical Therapist Health/Wellness Practitioner Music Therapist Behavioral Optometrist Other Comments / Questions (Optional) In the event of any problems with this application form please e-mail info@berardaitwebsite.com.

© Berard AIT Website.com 2007