Form To File

2008 - 2009

To pay on-line:
	Complete the form on this page to pay dues on-line by credit card or PayPal-linked checking account.

To pay off-line:
	Please download and print the Application Form. Mail it with a copy of your ADA membership card.
	Make check payable to Miami Dietetic Association and mail to: Cristina Scally 16221 SW 85 Ct Miami, FL 33157

APPLICATION STATUS:

New Member Renewal

CLASSIFICATION:
Select membership class (if dues paid by Dec 31, 2008)

Active RD ($35.00 )

Active DTR ($25.00)

Retired ($15.00)

Student ($15.00)

First Name:

Last Name:

Address line one:

Address line two:

City:

State:

Zip Code:

Phone #:

E-mail address:

Confirm E-mail address:

Title:

Place of Work:

Area of Expertise:

ADA member #:

FL Licensure #:

PAYMENT:

Online payment is processed only through PayPal. All you need is credit card info, name, and address, or your current PayPal login ID. A receipt will be e-mailed from PayPal.

Note: Your credit card statement will say PayPal.

Information about PayPal

You must complete both steps below to process your membership.
Note: Membership dues can be paid with cash or check at monthly meetings.

1.Press the Submit button below to start the application process. You will automatically be taken to a Payment page.

2.The PayPal forms must be completed to process your dues payment.

APPLICATION STATUS:	New Member Renewal
CLASSIFICATION:	Select membership class (if dues paid by Dec 31, 2008)
	Active RD ($35.00 )
	Active DTR ($25.00)
	Retired ($15.00)
	Student ($15.00)
First Name:
Last Name:
Address line one:
Address line two:
City:
State:
Zip Code:
Phone #:
E-mail address:
Confirm E-mail address:
Title:
Place of Work:
Area of Expertise:
ADA member #:
FL Licensure #:
PAYMENT: Online payment is processed only through PayPal. All you need is credit card info, name, and address, or your current PayPal login ID. A receipt will be e-mailed from PayPal. Note: Your credit card statement will say PayPal. Information about PayPal You must complete both steps below to process your membership. Note: Membership dues can be paid with cash or check at monthly meetings. 1.Press the Submit button below to start the application process. You will automatically be taken to a Payment page. 2.The PayPal forms must be completed to process your dues payment.