AFON Form AFON application2021 Association Friend of NRRTS Application (AFON) NATIONAL REGISTRY OF REHABILITATION TECHNOLOGY SUPPLIERS Any charity or non-profit involved in the rehabilitation industry or profession not otherwise eligible to be a NRRTS registrant but meets the criteria for Association Friend of NRRTS (AFON) as established by the Corporation may be eligible to be affiliated as an AFON. AFONs are state, professional or national associations. An AFON must be sponsored by a NRRTS Registrant in good standing and approved by the Board of Directors of NRRTS as meeting all criteria as established by the corporation. There is no annual fee. Five (5) complimentary FON affiliations (IFONs have access to NRRTS Education at 50% off and can participate on the NRRTS Listserve and a subscription to DIRECTIONS Magazine) AFON corporate logo with hot link to corporate AFON web site on www.nrrts.org Right of First Refusal on Event Sponsorships AFON corporate logo on the back cover of DIRECTIONS Magazine. NRRTS Registrant Name (Sponsor) First Last Company NameCell PhoneEmail I recommend the company noted above is an asset to our industry and will be an honorable CFON. Signature of NRRTS Registrant -NRRTS will obtain on your behalf if you don't have one.(Proposed) Association Friend of NRRTS informationAFON Primary Contact (name of individual)* First Last Company Name*Corporate Phone Number*Company Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Contact Name* First Last Primary Contact Cell Phone*Primary Contact Email* Company Phone*Rehab Products and Services Supplied: (Check all that apply)*Wheeled mobilitySeatingAlternative positioningAugmentative communicationADL ProductsOther (please list)If you chose "Other" please describe:Complimentary Association Friends of NRRTS affiliationsPlease provide name and contact information for the (5) complimentary Association Friends of NRRTS affiliations. 1. Complimentary AFON* First Last Email* 2. Complimentary AFON First Last Email 3. Complimentary AFON First Last Email 4. Complimentary AFON First Last Email 5. Complimentary AFON First Last Email Association Friend of NRRTS (AFON) applicant Signature*Proposal will not be processed without signature of proposer, AFON primary contact and Date. Date Signed MM slash DD slash YYYY An annual renewal will be sent in January of each year to request updated published information about the organization and an update on its contribution to the rehab industry. Send completed form, payment of $1500USD (NRRTS can invoice), high-resolution logo in JPEG (minimum of 300 dpi) to Amy Odom