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* 1. Name

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* 2. Credentials

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* 3. The Academy # (previously ADA)  - MUST be an AND member to join NEPAND

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* 4. Is this your first time joining NEPAND?

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* 5. How will you be paying for your NEPAND membership?

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* 6. Home Mailing Address

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* 7. Home Zip +4 (if you don't know your +4 please go to www.usps.com and enter your entire street address)

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* 8. Preferred phone #

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* 9. Personal Email

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* 10. Secondary Email

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* 11. Indicate your current employment setting:

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* 12. Indicate your current practice area:

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* 13. Do you have any suggestions for fundraising opportunities?

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* 14. What is your biggest barrier to attending the Fall or Spring NEPAND seminars and how can we make the seminars more desirable or easier for you to attend?

Thank you for filling out the NEPAND 2019-2020 membership application. Remember, if you have not already paid, you have the option to pay for your membership online using PayPal or by mail with a check. Please refer to question five above for appropriate payment links. For further information about the NEPAND membership please visit http://www.eatrightnepa.org/#!joinus/cee5 or contact Molly Sweeney MS, RDN, LDN, CDE 2019-2020 Membership Chair at mollyannsweeney@gmail.com

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