Registration Status:(Required) Current NDVTA paid Member Non-NDVTA Member If you need to verify your membership status, please refer to website (membership tab/2022 paid members) ***Online payment can be made on website- Contact/Pay online ($5.00 convenience fee will be added to cover credit card service fees)*** Return application and remittance by mail to: Miranda Langerud 54 N. Stanley Dr. Lincoln, ND 58504 Personal Information For executive board members only. Ensure name is how you prefer printed for your CE Certificate*** Name First Last Maiden (if applicable) Address Street Address City State / Province / Region ZIP / Postal Code Phone number: E-mail address: DATE PD. AMT. PD. TYPE OF CHECK CHECK #
