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2012-2013 MDDA MEMBERSHIP FORM **Academy of Nutrition and Dietetics Membership is Required** Please submit proof of Academy Membership Membership Directory Information Name: Credentials: Title: Registration/ Academy Number: Place of Employment: Work Address: (City) (State) (Zip) Work Phone: Work Fax: Home Address: (City) (State) (Zip) Home Phone: Cell Phone: Preferred Email: (MDDA to send notices and newsletters) 2012-2013 Dues are as follows: $25.00: active RDs and DTRs $15.00: retired RDs $5.00: nutrition/dietetic students Dues must be POSTMARKED by July 31, 2012 in order to be included in the Membership Directory for 2012-2013 and to avoid a late fee of $10.00. Proof Academy of Nutrition and Dietetics Membership (copy of Academy card or receipt) If postmarked after July 31, 2012, submit a late fee of $10.00 in addition to dues. Please send check payable to MDDA, 2012-2013 Membership form, and proof of Academy membership to: Christy Fernandez MDDA Membership Chair 1031 Wildbird Lane Collierville, TN 38017 If you would like to make a contribution to the MDDA scholarship fund, please check the appropriate box: $5.00 $10.00 $25.00 Other Amount: Thank you!
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