American Diabetes Association: Survey - ERP Logo/Language Request Form

*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

4.

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)}

5.

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

6.

Question - Not Required - Comments:

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