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Final Program - American Academy for Cerebral Palsy and ...

Final Program - American Academy for Cerebral Palsy and ...

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Please TyPe or PrinT Clearly DATE SUBMITTED: 2008 AACPDM Membership Application Name (First/Given) (Middle) (Last/Family) Degree Date of Birth Birthplace Citizenship City State/Province Country Specialty Diplomat Yes No remiT To aaCPdm offiCe: 555 E . Wells St ., Suite 00 Milwaukee, WI 53202-3823 + (4 4) 9 8-30 4 Fax: + (4 4) 276-2 46 Types of Membership: Fellow - Must have a minimum of a Bachelor’s Degree . International Corresponding - Must reside outside of the United States and Canada . Trainee/Student/Resident - Professional attending post-entry professional training . This membership category is good for two years . After two years, you will automatically become a Fellow member . Curriculum vitae must accompany all applications Professional address Institution (if any) Street City State / Province Country Postal Code Telephone Fax E-mail Home address Street City State / Province Country Postal Code Telephone Fax E-mail Specify address to which AACPDM correspondence is to be directed: Professional Home name of sPonsor Having a sponsor is no longer required; however, if a member of AACPDM recommended that you join, please print their name here: Undergraduate education Degree Year Graduate education, including professional school Degree Year Other post-graduate study, including fellowships and residencies

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