Central Arizona Academy of Nutrition and Dietetics District

Membership Application

(Membership year is June 1stto May 31st)

First Name:LastName:ProfessionalSuffix:

MailingAddress:

CityStateZip:Academy MemberNumber:

PreferredPhoneNumber:PreferredE-Mail:

CurrentJobTitle:Place ofEmployment:

CongressionalDistrict:

LegislativeDistrict:

(This information can be found on your Voter ID card)

Are you interested in being a volunteer in yourAZ-ANDDistrict? YES NO

Please let us know in what ways you might want to getinvolved:

Comments or questions? Please contact Margie Tate

Qualification of AZ-AND District Membership:

Academy of Nutrition and Dietetics members residing in Arizona are automatically members of the Arizona Academy of Nutrition and Dietetics. Any person who is a member in good standing of the Academy of Nutrition and Dietetics is eligible to become a member of an Az-AND District. Members may hold membership in more than one district. The districts appreciate your financial support and your attendance at local meetings and events. Academy dues do not include local District association membership. We rely on your dues to provide local activities.

Please Indicate Your Membership Type: / Central District / Amount Due
Voting Member
Active RD or DTR -Active Member ofAcademy / $35.00 / $
Retired RD or DTR -Active Member ofAcademy / $25.00 / $
Non-Voting Member
Student or DieteticIntern / $15.00 / $
Allied Health Professionals / $40.00 / $
Donations
AcademyFoundation / $
AZANDDonation / $
Susan Grogan Memorial ScholarshipFund / $
Rissa Miller MemorialFund / $
Credit Card Fee
Using CC or Debit card to pay dues / $1.00 / $
Total Amount Enclosed / $

Please complete this application and mail with a check payable to your specific district association at the following address:

Central District
Lee Renda
2615 N Hayden RD 123
Scottsdale, AZ 85257

For Office Use Only.Date:

Cash:

Check#.

Credit Card#.

Paypal: