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ADAP Advocacy Association

Registration Profile

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Password:
Confirm Password:

Personal Information

First Name:
Middle Initial:
Last Name:
Title:
Company/Organization:
Mailing Address:

City:
State:
Zipcode:
Phone:	( ) - ext.
Fax:	( ) - ext.

Please check all that apply.

ADAP Recipient
ADAP State Directory
AIDS Service Organization
Government Agency (other than ADAP)
Legislative Staff for Member of Congress or Executive Branch
Lobbyist for Trade Association
Mid-Level / Health Professional (i.e., P.A., N.P. / R.N., L.P.N.)
News Media
Pharmaceutical Company
Physician
Other: Health-Care Related (i.e., hospital, pharmacy, therapy)

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