WVTRA

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:

City:

State: Zip:

County:

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:

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

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West Virginia Therapeutic Recreation Association
WVTRA,
WV Rehab Center, Institute, WV 25112. (304) 766-4821

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