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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 will obtain a minimum of 300 clock hours of active involvement in clinical management activities with individuals who stutter over my 3 year renewal period. These activities are broadly defined and include diagnosis, treatment, clinical supervision, referrals, consulting, treatment maintenance activities. Signature______________________________ Date__________________ Fax # ______________________________________________________ ASHA
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