American Diabetes Association:

Education Recognition Program Logo/Language Request Form

*All materials that display the ADA logo must be approved by ADA prior to use. After submission you will receive an email containing electronic versions of the ADA ERP logo along with the logo use policy within 24-48 hours.

*1.

Question - Required - Program ID#

*2.

Question - Required - Your Name:

^{(only the coordinator may request electronig versions of the ADA Education Recognition logo and language.)}

*3.

Question - Required - Email Address

Question - Not Required - Please indicate where you will be placing the logo/language:

	DSME Program Brochure or Pamphlet
	DSME Program Website
	DSME Program Newspaper Article
	Other

^{(Please Note: The ADA Education Recognition logo/language may not be used on letterhead, business cards or forms)}

Question - Not Required - If you select "Other" from the question above, briefly describe:

Question - Not Required - Comments:

(Maximum response 255 chars, approx. 5 rows of text)