Interest in Local Chapter Involvement Question Title * 1. If you would like to network with other CDI professionals in your area please fill in your demographic information. (Required.) Name: * Company: * Address: * Address 2: City/Town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * Country: * Email Address: * Phone Number: Question Title * 2. Are you an ACDIS member? (Required.) Yes No Question Title * 3. Are you willing to present on a topic you have addressed at your facility? (If yes, please include your topic suggestion within the comment box.) (Required.) Yes No Comment (Topic you'd like to present or learn more about) Question Title * 4. Would your facility be willing to host a webinar/teleconference meeting? (Required.) Yes No Other (please specify) Question Title * 5. Would you be willing to serve in a leadership role for the networking group? (Required.) Yes No Other (please specify) Done