Florida Symposium Stipend Application (Please fill out the form below to apply.) (*) First Name: Please enter your first name. Middle Initial: (*) 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: (*) City: Please enter the city. (*) State: must contain only A-Z characters (*) Zip Code: Please enter your Zip code. +4: (*) Email: Please enter a valid e-mail address. (*) Telephone: Please enter a contact number. I am applying for the following stipend:- Select One -Florida Symposium StipendFlorida Symposium Student StipendPlease select desired stipend. (*) Have you ever attended before? YesNoPlease make a selection. (*) List at least three (3) objectives for participating in this experience:Please explain. (*) Explain how participating in the symposium will enhance your dietetics career: Please explain. (*) What are you most looking forward to at the symposium? Please explain. (*) AND member since (year): Please enter the year. (*) Number of years lived in Florida: Please select. (*) Member of FAND since (year): Please enter value. (*) Member of District: 1-Broward2-Orlando3-Gainesville4-Jacksonville5-Miami6-Tampa7-Tallahassee8-Pinellas9-Palm Beach10-West Florida11-Panhandle12-Cypress13-Manasota14-Southwest FL15-Space Coast Please select your member district. (*) Since (year): Please enter a year.