Please tell us which ACDIS local chapter you belong to (or wish to join) and complete your contact information below.

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* 2. Please complete your contact information.

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* 3. What is a secondary email address that may be used to contact you?

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* 4. Which best represents your reason for filling out the local chapter roster?

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* 5. Are you an ACDIS member?

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* 6. Are you willing to present at a local chapter meeting?

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* 7. Are you willing to host chapter meetings at your facility?

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* 8. Are you interested in serving in an officer/leadership role?

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* 9. What is your job title?

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