AAADAC
PO Box 45386
Little Rock, AR 72214

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New Membership or Renewal Application
(Please Print)
Job Title/Position:____________________________________
Name:____________________________________
Address:__________________________________ City, State, Zip:______________________________________
Home Phone:________________________________________
County:___________________________________
Organization:______________________________
Work Phone:________________________________________
Certified/Licensed as:____________________________________________________________________________
Signature:______________________________________________________________________________________
New Membership - $25.00            ____Y           ____N
Please mail membership
Applications to:
AAADAC
PO Box 45386
Little Rock, AR 72214

Membership Renewal - $25.00    ____Y           ____N
I Have A Member Certificate        ____Y          ____N
I Need a Renewal Sticker             ____Y          ____N