Resident Scholarship Application for Legislative Conference
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Resident Scholarship Application for Legislative Conference

Applicant Information

Last Name
First Name
Suffix
Home Street Address
Apartment/Unit
Home City
Home State
Home ZIP
Phone
Email

Residency Information

Residency Program
Residency Year
Please submit a note of approval from your Residency Chair

Advocacy Involvement

Have you attended an AADA Legislative Conference in the past?
Have you been involved in advocacy activities?
If yes, please list your involvement.
Were you referred to the Legislative Conference by a colleague(s)? If so, please list.
Please tell us why (max. 1 page) you would like to attend the Legislative Conference and become involved in AADA advocacy activities?
Please read the following agreement and check the box before submitting your application.