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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. 717-614-8663)
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:
Expiration year:
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.