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Your Name

* First Name:
* Last Name:
* Email:	* This will be your login ID
* Password:	(must be at least 6 characters long)
* Confirm Password:

WEMTA Membership Information

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Work Information

* Organization Type:

WI Public School District

My building is not listed above. I want to enter my Primary Building.

* Primary Building Name:

* Address Line 1:

Address Line 2:

* City:

* State/Country:

For United States and Canada:

For Other Countries:

State:
Country:

* Zip:

WI Private School

Business

My Business is not listed above. I want to enter my Business.

* Business Name:

* Address Line 1:

Address Line 2:

* City:

* State/Country:

For United States and Canada:

For Other Countries:

State:
Country:

* Zip:

Organization/University

My Organization is not listed above. I want to enter my Organization.

* Organization Name:

* Address Line 1:

Address Line 2:

* City:

* State/Country:

For United States and Canada:

For Other Countries:

State:
Country:

* Zip:

Individual/Retiree

* Position / Title:

Phone Number:

Ex: 999-999-9999

Ext.

Fax Number:

* Do you Require Special Accommodations?

	Yes * Please tell us about your Special Accommodations:
	No

Home Information

Home Address:

Home City:

Home State/Country:

For United States and Canada:

For Other Countries:

State:
Country:

Home Zip:

Home Phone:

Ex: 999-999-9999

Cell Phone:

Ex: 999-999-9999

Contact Preference

* Contact me at:

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Categories You Belong To

Please select which categories are important so that we can better meet your needs - matching you to trainings and workshops that pertain to your position/role and ultimately to provide the tools and training to perform your job(s).

CESA:	Need help finding your CESA? Go here
	For help with answering the 3 questions below, go to the Wisconsin State Legislature Website
Federal Rep #:
State Assembly Rep #:
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