| Mississippi Association of Diabetes Educators
~ Miss-ADE Membership Application / Renewal July 1, 2007 until June 30, 2008 |
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| Click On > Instructions to Print This Form | ||
| Mission: Dedicated to advancing the role of the Diabetes Educator, and improving the quality of diabetes education and care of the people we serve. |
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| Miss-ADE dues of $25.00 per year and are
due by July, 1st. Please send this completed form and your dues to: Miss-ADE, Inc. |
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| Name: ____________________________________ Your Credentials: _______________________ | ||
| License # (for CE purposes): _________________________________ State: __________________ | ||
| Are you an AADE member? Yes - No *If member, membership #: ________________________ | ||
| * Must be furnished to determine appropriate status. | ||
| HOME Address: ___________________________________________________________________ | ||
| Home Phone #: ___________________ Fax: __________________ Email: ____________________ | ||
| WORK Address: Institution: ______________________________ Street / Box #: _____________________________ |
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| City: ______________________________________ State: _______________ Zip: ______________ | ||
| Work Phone #: ___________________ Fax: __________________ Email: _____________________ | ||
| Are you a CDE? Yes - No Initial year of Certification: _______________ | ||
| Please circle / answer the following questions: | ||
| 1. Areas of interest in which you would be willing to serve: | ||
| Program Committee Membership Advocacy | ||
| 2. Would You be willing to serve a
2-year session as an elected officer of Miss-ADE? |
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| President Elect Secretary Treasurer Nominating Committee Historian | ||
| 3. How would you like the Newsletter to come to you? | ||
| Regular Mail E-mail Website | ||
| 4. Do you have a program that is already
approved for CEU’s that you would like to
present at a quarterly meeting? |
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| ________________________________________________________________________________ | ||
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