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Florida Legislative Day Stipend Application Form
Please enter your first name.
(*) Last Name:
Please enter your last name.
(*) AND Number:
Please enter your ADA member number.
(*) Address Line 1:
Please enter your address.
Address Line 2:
Please enter the city.
must contain only A-Z characters
Please enter your Zip code.
Please enter a valid e-mail address.
Please enter a contact number.
(*)I am applying for the following stipend:
Florida Legislative Day Stipend
(*) Event Start Date:
Please select an event start date.
(*) Event End Date:
Please select an event end date.
(*) Cost to attend; include proposed expenses:
Please enter a numeric amount.
Have you ever attended this event before?
(*) Why is public policy important to the future of dietetics?
Please answer this question.
(*) List at least three (3) objectives for participating in this experience:
(*) Explain how this opportunity with our legislators and public policy will enhance your dietetic career:
(*) AND member since (year):
Please enter the year.
(year) (*) Number of years lived in Florida:
(*) Member of FAND since (year):
Please enter value.
(year) (*) Member of District:
Please select your member district.
Please enter a year.
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