2012-2013 MDDA MEMBERSHIP FORM by 4Z22eGa6


									                          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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