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GDF Stipend
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1.
First Name
(Required.)
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2.
Last Name
(Required.)
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3.
Street Address
(Required.)
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4.
City
(Required.)
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5.
State
(Required.)
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6.
Zip Code
(Required.)
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7.
Phone Number
(Required.)
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8.
Email address
(Required.)
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9.
AND Member Number
(Required.)
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10.
License #
(Required.)
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11.
Years experience in Dietetics
(Required.)
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12.
Currently employed (full or part-time)
(Required.)
Yes
No
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13.
Educational program of interest
(Required.)
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14.
Location / Date
(Required.)
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15.
How will the conference you wish to attend benefit you or enhance your ability to practice?
(Required.)
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16.
I understand that the awarded funds will be released once I attend the educational program, and after I submit a completed expense report to GDF. I also understand that the award is not transferable, and may be withdrawn if not utilized within 1 year of the award date.
I know that I am required to, within 90 days following attendance at the conference / symposium, write an article for the Peach Press newsletter regarding the experience and knowledge gained.
(Required.)
Yes
No