To join WPADE please print out this application and send to:
Amy Sullivan, RD, LDN, CDE
Amy.Sullivan@chp.edu
WPADE Membership Application
July1, 2009 – June 30, 2010
New______ Renewal______
Name_____________________________________________________
Credentials ________________________________________________
Address (home) ____________________________________________
Phone (home) ______________________________________________
Address (work) _____________________________________________
____________________________________________________________
Phone (work) ______________________________________________
Email Address ______________________________________________
Employer __________________________________________________
Position ___________________________________________________
Specialty __________________________________________________
Is your practice recognized by the ADA? Yes____ No ____
Are you a CDE? Yes___ No ___
Are you an AADE member? Yes___ No___
Indicate which WPADE committee you would be interested in: Newsletter/Website ___
Community Events_____ Program _____
DO YOU WANT YOUR NAME RELEASED TO OTHER ORGANIZATIONS FOR EDUCATIONAL MEETINGS? Yes_____ No ____
The newsletter will be sent to you by email, unless you indicate that you do not have email or do not wish to have the newsletter sent to you by this method.
I do not have email or I do not wish to have the newsletter sent to me by email (If you check yes, the newsletter will be mailed to you by US mail). Yes ___
Membership fee: $25.00
Send your check for membership, payable to WPADE, with this application to:
Amy Sullivan
4905 Havana Drive
Pittsburgh, PA 15239
