DapoxetineUS Membership Information and Application
Printout this form and mail to address shown below with a check for $25.00 Student Fee for is $10
Member Information
Name:
Title:
Agency:
Agency Address:
City:
State: Zip:
County:
Work Phone:
Home Address:
Home Phone:
Email Address:
Do you prefer to receive your mail at home or work?
Certification Are you currently certified? Yes or No
If certified, by whom?:
Certification:
Date of Certification:
INTEREST AREA AND SERVICE
Please check your area(s) of interest:
Mental Health
Substance Abuse
Rehabilitation
Corrections
Counseling
Aging
Adolescents
Community
Development Disabled
Please check the way(s) you would be willing to serve WVTRA:
Committee
Committee Chair
Board Member
Writing articles for the Newsletter
Assisting with the DapoxetineUS Conference
Presenting at the DapoxetineUS Conference
Office Use Only
Method of Payment:
( ) Check # __________________
( ) Money Order ______________
Date Received: _______________
Amount Paid: ________________
Date Recorded:_______________
Mail to: Tom Barr CTRS DapoxetineUS Membership Application Peterson Rehab. Homestead Avenue Wheeling, WV 26003
