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Orange Association of Diabetes Educators
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Membership
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Orange ADE Membership Application
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July 1st, 2008-June 30, 2009
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| Name: __________________________________________________________________ |
| Address: ________________________________________________________________ |
| City: _________________________________State:__________ Zip:________________ |
| Phone Numbers: |
| Home: _________________Cell:___________________Work:_____________________ |
| Fax: __________________ E-mail addresses: _________________________________ |
| Place of Employement: ____________________________________________________ |
| Address: ________________________________________________________________ |
| City: _______________________________State: _______________ Zip: ____________ |
| Preferred Mailing Address: Home Work |
| Professional Status: RN RD Pharm. Other Are you a CDE? Yes No |
| Are you a member of AADE? Yes No Member #________________ |
| I do not wish my email address or name made public to any vendor or professional memberships, other than for Orange ADE OK to share Do not share |
| Dues: $45.00 Corporate Professional Membership |
| Make checks payable to Orange ADE |
| Mail registration and check to: |
| Orange ADE |
| 1835 Newport Blvd. A 109 #165 |
| Costa Mesa, Ca. 92627 |
| Vist our website for Orange ADE for updates, education classes, programs and meetings. www.ocade.org |
Celebrating 22 years as a Chartered Chapter - August 2008