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SPECIALTY BOARD ON FLUENCY DISORDERS BRS-FD ANNUAL MEMBERSHIP FORM To maintain your BRS-FD, please complete the following information. Mail this contact information along with your check payable to “SBFD” for the amount of $70.00 (US) for your annual renewal fee. Please enclose a copy of your current ASHA membership card. PLEASE PRINT CLEARLY OR TYPE THE FOLLOWING: Name __________________________________________________ Professional Address Org_____________________________________________________ Street___________________________________________________ Suite/Floor_______________________________________________ City/State/Zip_____________________________________________ Phone_____________________________________Ext____________ Professional Email ________________________________________ Professional Web site_____________________________________ Clinical Management Activities I attest that I have maintained a minimum of 100 clock hours of active involvement in clinical management activities with individuals who stutter. These activities are broadly defined and include diagnosis, treatment, clinical supervision, referrals, consulting, treatment maintenance activities. Signature______________________________ Date__________________ Fax # ______________________________________________________ ASHA
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