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Please make sure to accurately fill this form. Please use your legal name, not a nickname as it will be used to issue your certificate.

Legal First Name*

Legal Last Name*

Cell phone*

CDA Council Number

Select the state you work in. If not working then one you live in.*

Business Type or Profession*

Email address* (for Business Accounts, for Administrative privileges, please use a business email address)

Valid email address

Has to be a valid email. Will be used to reset your password - if you need to.

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