Online SLADE Membership Application

The current membership year is January 1, 2010 through December 31, 2010.

Please provide the following member contact information:
* = Required field

First name	*
Last name	*
Date of birth	* mm/dd/yyyy
Preferred e-mail address	*
Confirm e-mail address	*
Preferred mailing address	*
Mailing address line 2 (optional)
City	*
State	*
Zip	*

Please provide your phone number(s) and indicate which is your preferred phone listing:

Please indicate your professional discipline:

Please provide your place of employment:

Place of employment

May we print this contact information in the online directory? *

	Yes
	No

Please indicate your interests in committee participation:

Are you a member of the American Association of Diabetes Educators (AADE)? *

	Yes (Membership #)
	No

Please list any specialty practice groups with AADE to which you belong:

Please select the appropriate membership category:

Membership category	Active Member, $25.00 (must be a member of AADE)
	Associate Member, $35.00

For office use only. Leave blank.

When you click "Submit" you will be taken to a page for payment through PayPal. You will receive confirmation after payment has been finalized.