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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? __________________________________________

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

PLEASE NOTE:  To be listed in the directory, dues must be paid by October 1.
 Annual Membership dues for PLD  $30.