Instructions: Please fill-in the blank or select one answer.
Date of Birth (mm/dd/yyyy):
/ /
Sex:
 Male Female
Years Certified as an ATC (1, 2, 3, etc.):
Primary Setting:
High School Clinic
  Clinic-Outreach College
  Professional Hospital
  Other (Explain)
NATA District (1, 2, 3, etc.):
Highest Degree Earned:
BS MS
EdD PhD
Other (Explain)