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* 1. Name (First Last)

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* 2. Degree(s)

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* 3. Jurisdiction/Affiliation

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* 4. Address

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* 5. City

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* 6. State

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* 7. Zip

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* 8. Phone

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* 9. Fax

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* 10. Email

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* 11. Are you a paid CACDC Member?

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* 12. Are you requesting Continuing Education Credits?

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