PSTAP Membership Application Please fill out the following information to apply for PSTAP Membership. QUESTIONS? Please contact 1-800-270-3352. Required fields are in Red. Applicant/Business Information Sponsor/Referral: Last Name: First Name: Mid Initial: Firm: Business Address: Address2: City: County: State: Zip Code: Telephone: (e.g. 800-270-3352) Fax: (e.g. 717-737-6847) Email: Applicant/Home Information Home Address: City: County: State: Zip Code: Telephone: (e.g. 800-270-3352) Mailing Address: Business Home Personal Information Gender: Male Female PTIN: Are you licensed: Yes No If Licensed : License Number: State: Date of birth: Are you admitted to practice before the IRS?: Yes No If Yes, Enter EA #: Chapter Preference: Buxmont Central Lehigh Valley Northeast Philadelphia South Central Southeast West Central Western PA Are you a member of: NSA NAEA AICPA PSEA NATP PICPA NAA Other Membership: Select Membership Category: Active - $199 Associate - $199 Student - $0 Have you ever held a membership in the PSPA/PSTAP: Yes No Has your membership lapsed in last 12 months? : Yes No How did you hear about PSTAP? (please check all that apply) A colleague referred me Name of Colleague: Direct Mail I attend PSTAP seminars Website Other Explain: Payment Information Credit Card Type: Visa Mastercard Card Number: Expiration month: 1 2 3 4 5 6 7 8 9 10 11 12 Expiration year: 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 CVM Code: Billing Information *** NOTE: Please do not enter a + or & symbol. Our credit card provider will not accept those values. Name on Card: Company: Address1: Address2: City: State: Zip code: Note: DUES ARE PRO-RATED THE SECOND YEAR OF MEMBERSHIP. Fiscal year ends June 30. Credit card payment in the full amount for one year will be charged upon acceptance of this application. I hereby state that the accompanying statements are correct to the best of my knowledge. I further state that I will abide by the by-laws of PSTAP and will practice according to the Code of Ethics and Rules of Professional Conduct adopted by PSTAP. (Please type your name here exactly as it was entered in the Applicant/Business Information section if you agree to the above statement) Last Name: First Name: Mid Initial: PSTAP dues are deductible by members as a business expense but not as charitable contributions for federal tax purposes. PSTAP is affiliated with the National Society of Accountants.