* 1. First Name

* 2. Last Name

* 3. Street Address

* 4. City

* 5. State

* 6. Zip Code

* 7. Phone Number

* 8. Email address

* 9. AND Member Number

* 10. License #

* 11. Years experience in Dietetics

* 12. Currently employed (full or part-time)

* 13. Educational program of interest

* 14. Location / Date

* 15. How will the conference you wish to attend benefit you or enhance your ability to practice?

* 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 I also understand that the award is not transferable, and may be withdrawn if not utilized within 1 year of the award date.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.

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