APDDA Membership Application

NOTE: THE BELOW NAME, ADDRESS, PHONE, FAX, AND E-MAIL INFORMATION WILL BE USED FOR PUBLICATION IN THE APDDA DIRECTORY

** Indicates Required Fields

Salutation	First Name**	Last Name**	Title

Position

Facility/Agency

Street Address**

City**	State**	Zip Code**
	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Phone	Fax	Email

Please Indicate Full, Associate or Agency Membership

Full Membership includes individual employed at executive levels of either: A public or private residential program that has an organization element of providing care and treatment for persons with mental retardation or other developmental disabilities, or Individuals who have administrative direction involving those programs by way of central (governmental) administrative capacity.

Associate Membership includes (a) individuals who have been former members, or (b) who have a professional or personal commitment to the purposes of the Association and who wish to have an affiliation with the Association in a non-voting, non-office holding relationship.

Agency Memberships are available for more than one full or associate member from an organization. An agency member may specify up to five individuals for membership benefits.

Membership Type: ** Full Membership - $100 Associate Membership - $75 Agency Membership - $300

Method of Payment: ** Check Purchase Order - Federal Tax ID # 52-1234390

INSTRUCTIONS:
PRINTED FORM ALONG WITH CHECKS/PURCHASE ORDERS SHOULD BE SENT TO:

Association of Public Developmental Disabilities Administrators
Robert D. Shrewsberry, Ph.D.,
APDDA Administrative Director
Southeastern Virginia Training Center
2100 Steppingstone Square
Chesapeake, Virginia 23320-2519
(757) 424-8379
Fax: (757) 424-8502A