Membership FSDPA

	* - required fields

*Name ::
*Credentials ::
*Specialty ::
Phone ::
*EMail ::

	Mailing Address
*Mailing Address::
*City ::
*State ::
*ZipCode ::

Membership Type ::
Other::

Message / Comments::


Agreement Information
FSDPA Agreement By submitting content, you represent and warrant that you own the proprietary rights, including but not limited to the copyrights, to that content, and that the reproduction, public display and performance, distribution and preparation of derivative works of that content, by FSDPA or thereof, will not infringe any third-party rights or any applicable law. You agree to defend, indemnify and hold harmless FSDPA, directors, officers, employees, agents and other representatives from and against any and all claims, demands or proceedings (including but not limited to legal costs and fees) in the event of your breach of this representation and warranty.


	I agree to the above terms