MEMBERSHIP FORM
Current dues:
Individual-$30.00
Group-5 or more $25.00 each
Please complete (print)
Name _________________________________________
Licensure/Credentials ___________________________
Preferred Mailing Address _______________________
_______________________________________________
Is this home or work address? ____________________
Employer:______________________________________
Phone: ________________________________________
Email address:__________________________________
Amount enclosed: ____________________
Please check one of the following choices:
_______ send information via regular mail
_______ send information via email
Make checks payable to PADDNN
Print Form and Send to :
Melody Wolf
315 Stanton Street
South Williamsport, PA 17702