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* 1. First Name

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* 2. Last Name

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* 3. Street Address

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* 4. City

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* 5. State

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* 6. Zip Code

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* 7. Phone Number

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* 8. Email address

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* 9. AND Member Number

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* 10. License #

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* 11. Years experience in Dietetics

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

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* 13. Educational program of interest

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* 14. Location / Date

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

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 I also understand that the award is not transferable, and may be withdrawn if not utilized within 1 year of the award date.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

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