MEMBERSHIP APPLICATION

PLEASE PRINT & MAIL TO KCRA

MEMBERSHIP APPLICATION (Rev. 12/04)

(Incomplete Applications will be RETURNED to you.)

 

A. IDENTIFYING INFORMATION (Please print)

Name ___________________________________________ Date of Birth_________

Home Address: _______________________________________ Business Name and Address:_______________________________________________________________________________________________________________________________________

____________ ___________________________________________________________

Home Phone:_______________________________ Business Phone: _______________

E-mail Address: ____________________________ Fax Number:___________________

Previous KCRA member? Yes _____ No _____ If yes, by what name? ______________

B. MEMBERSHIP TYPE AND INFORMATION (CHECK ONE)

1. ACTIVE MEMBER _____ ($85.00 - Must be reporting for one year)

TYPE OF REPORTER: Freelance _____ State Official _____ Federal Official _______ Hearing _____ Legislative _____Captioner _____ CART _____ Other _____________

REPORTING METHOD: Machine _____ Gregg _____ Pitman _____ Other (Explain) __________________________

DESIGNATIONS: (NOTE: PLEASE SUBMIT A COPY OF CURRENT CERTIFICATIONS)

CSR (List states) ________________________ RPR _____ RMR _____ RDR _____ CRR _____CBC _____ CCP _____ CLVS _____ CRI _____ Othe__________________

SUPPORT SERVICES: Computer-Aided Transcription _____ Conference Room _____ Litigation Support ______________Video _____ Realtime Translation _____ Captioning _____ Video Conferencing _____Interpreter _____ CART _____ Broadcast Captioning _____ Litigation Realtime _____

SCHOOL ATTENDED: _________________________________

How long have you been engaged in the active practice of reporting?_______________

Are you interested in donating time to the Pro Bono Program? Yes _____ No _____

2. ASSOCIATE MEMBER _____ ($35.00)

OPEN TO THE FOLLOWING (Check one):

Active member in good standing upon retiring (upon application to the Secretary) _____

Certified Legal Video Specialist _____

Anyone professionally associated with, or employed by, an active member in good standing _____

Teacher of shorthand reporting _____

Anyone qualified for active membership but residing outside the Commonwealth of Kentucky _____

3. STUDENT MEMBER _____ ($25.00)

Name of School __________________________________________________________

School Address __________________________________________________________

Name of instructor or school official _________________________________________

Signature of instructor or school official ____________________________ Date_______

4. VENDOR MEMBER _____ ($500.00)

C. ENDORSEMENT (Required by an Active Member in good standing)

KCRA Member (Print) _________________________________________________ Date _______________________________________________________________

Signature of Endorser _________________________________________________

D. CERTIFICATION

I HEREBY CERTIFY that the foregoing data is true and correct, and I understand that any false or misleading statement

shall be grounds for automatic expulsion from the Association.

Signature of Applicant __________________________________ Date _____________

MAKE CHECK PAYABLE TO KCRA AND MAIL TO: KCRA Executive Director

P.O. Box 4463

Midway, KY 40437-4463

859-846-4847

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