Directory of Diabetes Education Services
Request for Listing

Request for
1997-1998 Directory Listing
Change of Address Form

Date _____________________

Please check one:

_____ I m not included in the current directory and would like to be included in the next one

_____ I am included in the current directory but am submitting change of address information
Name ______________________________________________
Organization ________________________________________________
Address ______________________________________________
Phone _____________________

The next directory will be published in Spring 1997. You will be sent a directory listing questionnaire in Winter 1996. Those in the current directory will automatically be sent a questionnaire--you do not need to send in this form unless your address has changed.

Mail/Fax to:

Diabetes Control Program
P.O. Box 26110
Santa Fe, NM 87502-6110
Phone (505) 827-2953
Fax (505) 827-0021

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