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     Name_____________________________ Date _____________ 

     Street Address_____________________________

     City,   State.   Zip __________________________

     Home Phone (                    ) Work Phone (                    )

     E-Mail ____________________

     Member’s Qualifications: (Education and Certification)
 

     Current Professional Position:  (Name of school and district, private practice, etc.)

     How did you hear about PLD/SE? __________________________________________

     Enclose annual membership dues of $30.00 (runs from May to May).  Make check payable to PLD/SE.

      PLEASE NOTE:  To be listed in the directory, dues must be paid by October 1.
      Annual Membership dues for PLD/SE   .. . . . . . . . . . . . . . . . . . .     $33. *

       I wish to make a donation to PLD/SE   . . . . . . . . . . . . . .. . . . .      _____

      Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . .      ______

  * Membership in IBIDA is included in the membership fee. (Illinois Brach of the International Dyslexia Association.)