MEMBERSHIP APPLICATION
Name ____________________________________
Degree _____________________
Organization/Institution:_______________________
Street Address:_________________________________
City _____________________________________
State _______ Zip ____________
Phone _______________________________________ FAX___________________
E-mail ________________________________________
MEMBERSHIP TYPE REQUESTED
CIRCLE APPLICABLE BULLETS AND RESPONSES
Individual ( annual dues $35 )
Are you currently active in treating individuals with HIV disease? Yes ____ No____
If yes, current number of patients per week? ________________________
Can DAAC furnish your name to patients with HIV disease in your community seeking a referral?
Yes____ No_____
Organization ( annual dues $2,000)
A check in the amount of $ ___________ is enclosed.
Visa/Mastercard#:_____________________________
Name as shown on card: ____________________________________________
Expiration Date: _________________
Signature:_____________________________________
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