DSHA MEMBERSHIP APPLICATION
Please print application, complete, enclose $25 dues made payable to DSHA*, and mail to: Patricia Hammond DSHA Membership Chair 809 North Country Club Drive Newark, DE 19711 * Note: For first-time members, application fee is reduced to $12.50 after August 31st of the membership year._____Check here if you do NOT wish to be included in the next DSHA Directory or directory update.
Type of Membership requested: Full Associate Student
Name:
(Circle: Mr. Miss Ms Mrs. Dr.)
Address: (Check preferred mailing address)
Home:
Work:
Telephone:
Home: ( )
Work: ( )
E-mail Address: ____________________________
Professional Title:
Highest Degree:
University granting highest degree:
Specialization:
___ Speech-Language Pathology
___ Audiology
___ Other (Please explain interest in DSHA): ______________________________
_________________________________________________________________
ASHA Member: YES NO
CCC: YES NO
Certificate holder only
Private Practice: Full-time Part-time No
Do you wish to be listed in the membership directory under the private practice section? YES NO
State License: YES NO
Other State License (Please list): ________________________________________
Membership Dues: $ _____________
Year: _____________