Application for Student Membership

There are two ways to join:

1.  Complete the form below, enter credit card information and submit electronically. 
(Once you submit your information you will receive a confirmation message that appears at the top of the screen).

 or

2.  Complete the form below, print and send paper copy of application with check or purchase order to:

ATTUD
2424 American Lane
Madison WI, 53704
+1 (608) 268-4716
info@attud.org
Fax: (608) 443-2474

Personal Information:
Title:
First Name:*
Note: Fields marked with * are required.
Middle Initial:
Last Name:*
Degree Program:*
Address:
Organization/
Institution*
Street*
Country*
Other Country
Province/State*
Other State
City*
Postal/Zip Code*
Telephone:*


Format: (000) 000-0000
Email: *

Please describe your area of interest.
Do you have previous tobacco experience?

Please describe your previous experience.

Signature and Membership Agreement: *
Please read the following statements and check that you agree.
I confirm that the information given in this application form is accurate.
I have read and agree with the mission statement and goals of ATTUD.
I understand that I may not use the name of the organization to promote personal endeavors.
I understand that the organization has the right to accept or decline any application.
I understand that the organization has the right to revoke membership due to unethical conduct.
I confirm that I am tobacco free.
I confirm that I am currently active or have been historically active in the treatment of tobacco use and dependence.
I am electronically submitting my signature by checking here. Date submitted:
Format:YYYY-MM-DD
I do not want to have my contact information included in the member listing section.


Do you receive funds from the tobacco industry?
Yes No  

Student Membership Category (US $45.00 Annual Fee)
Credit Card Payment Only:
Card Type:
Card Number:
Name on Card:
Billing Address Street:
City
State
Country
Zip Code:
Expiration Date:
Expiration Year:
CVV No.:
Captcha:

Can't read the above security code? Refresh

No application can be processed until payment is received.

The Membership Committee Chairperson or his/her designee will review all information received. Once the the application has been processed, an e-receipt will be sent. If an applicant does not receive the confirmation, they are encouraged to contact the Membership Committee Chairperson, Scott Irwin, PhD, CTTS, myquitcoach@gmail.com.

NOTE: When you submit your credit card information, a confirmation message will appear at the top of this screen. Please only submit once.