A Texas district association that is the advocate of the dietetic profession serving the public through promotion of optimal nutrition, health, and well being

MEMBERSHIP APPLICATION

September 2010- May 2011

NAME________________________________________________________________________________

HOME ADDRESS ___________________________________________________________________

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BUSINESS NAME_______________________________________________________________________

BUSINESS ADDRESS____________________________________________________________________

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PHONE (HOME) ___________________________ (BUSINESS)__________________________

FAX____________________________ E-MAIL___________________________________________

APPLICABLE TITLES: RD_____ LD_____ BS_____ MS_____ MA ____ PhD_____

(Check all that apply) DTR_____ PLD______ CDM_____ CDE_____ CNSD_____

ADA MEMBERSHIP CATEGORY:

Active_____ Inactive______ Student______ Retired_____ Life______ Honorary ______

Associate______ Tech______ Other_____

AREAS OF PRACTICE/EXPERIENCE: _______________________________________________________

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DUES

ACTIVE MEMBERSHIP $25.00 _______

FULL-TIME STUDENT $10.00 _______

RETIRED ADA MEMBERS $10.00 _______

NON ADA MEMBERS $35.00 _______

ENDOWED SCHOLARSHIP DONATION:

(Make separate scholarship check payable to TDAF) _______

TOTAL _______

MAKE YOUR CHECK PAYABLE TO ETDDA

MAIL FORM AND MEMBERSHIP DUES TO: Lauren Marty MS, RD, LD

4411 Kinsey Dr. #726

Tyler, TX 75703