Membership Application

 
Thank you for your interest in PeDRA. Please read about membership categories, member responsibilities, and the PeDRA bylaws, then fill out this form as completely as possible. Additional information may be requested by the Membership Committee after initial review of this application.
 
 
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First Name:*
Last Name:*
Degree(s):
Institution/Organization:
Department/Division:
Position:
Address:
Phone:
Fax:
E-mail:*

Membership Category:*

Board Certification or Equivalent (check all that apply):
Active Member Applicants: please list the names of two Active Member Sponsors
Sponsor #1:
Sponsor #2:
Trainee Member Applicants: please complete the following
PeDRA Active Member Sponsor / Mentor
Training Program:
Program Director:
Program Director Email:
Dates of Training Period:
Affiliate Member Applicants: please list your Active Member Sponsor/Principal Investigator
Sponsor/PI:

Are you considering Emeritus status? (retired from active practice and/or 70 years or older):*
Have you participated in the development of PeDRA (for example, worked on a committee or meeting planning) in 2012 and/or 2013?:*
PeDRA Bylaws:*