* 1. Name (First Last)

* 2. Degree(s)

* 3. Jurisdiction/Affiliation

* 4. Address

* 5. City

* 6. State

* 7. Zip

* 8. Phone

* 9. Fax

* 10. Email

* 11. Are you a paid CACDC Member?

* 12. Are you requesting Continuing Education Credits?

T