OSTC Inc. - Application

Oregon Society of Tax Consultants, Inc.

INITIAL APPLICATION:
Please complete all applicable lines

REGULAR - (Full dues)
ASSOCIATE - (Full dues)
CONTRIBUTING - (1/2 dues)



(1)	Name	Home Phone

(2)	Business Name	Bus. Phone

(3)	Are you an employee? Yes / No	Fax. Phone

(4)	Email Address

(5)	Mailing Address
	City	Zip Code

(6)	Business Address
	City	Zip Code

(7)	Federal ID #	Oregon License

(8)	Annual Dues (July 1st - June 30th) $60.00	$
(9)	Months prorated dues @ $5.00 /month	$
(10)	Initiation Fee $10.00	$
	Total Remittance	$

(11)	Have you ever been a member of OSTC? Yes / No, Comments
(12)	How many years have you prepared tax returns?
(13)	Have you ever had a professional license revoked or suspended? Yes / No, Comments
(14)	Have you ever been officially disciplined by a regulatory agency? Yes / No, Comments
(15)	Are you a member of another professional organization? Yes / No, Comments
(16)	Name of organization if answer to 15 is yes?
(17)	Have you ever been expelled, suspended or disciplined by a professional organization? Yes / No, Comments

(18)	I hereby certify that the above statements are correct to the best of my knowledge. I will abide by the bylaws and code of ethics adopted by the Society. In the event my membership is terminated for any reason, I agree to return my certificate of membership. I hereby receipt for a copy of the code of ethics.

	Signature_____________________________	Date__________________

Local Unit Use Only:

Name:_________________________

Address:_______________________

______________________________

Date to State Trea:_______________

State Treasurer Use Only:

Date Received:__________________

Unit Check No:_________________

Date to St. Sec:_________________

State Secretary Use Only:

Date Received:__________________

Membership Materials

Issued:________________________

Certificate No:__________________

Mail to Dona Cole, OSTC State Treasurer
1810 15th Street Ste A
Springfield, OR 97477