APPLICATION FOR BREASTFEEDING RESOURCE DIRECTORYHays.202010-01-19T18:46:00Z2010-01-19T18:46:00Z1100357184713670811.0000QWN0aXZlTWltZQAAAfAEAAAA/////wAAB/D/CgAABAAAAAQAAAAAAAAAAAAAAAAgAAB4nO1ZfWxb 1RU/79lJHTdp3DQtaVbAdWiBgsN7zx9xaAPx+0rKnCaQ0Eyat9axX1sXf2S2AwldmEnKx1SkVZo2 iQlVowz+mAaCwTbBpqkrkybQNIa2aev+GB+r9sekSftnmoYE2e/e95y4aVqSgjSYOC8/3/vO/Tzn nnvuuS+/fWPj20++0PkOLaPbyEUfLDRRYx1PcMDJRyQ67x8sLCzU2Auf0aeK3gfWOWvoRtoAsDX3 OLwmpF5gPdAMtAAbnLLP6NNPd1ERT4X8ZFABaYlmlruCy9IWWEytr4YPqTuy71+v9Dz+uuBCvr/d 5u0nleJrGvFC8sAD1cZ3fci4tbS+LENZyPxRxhcv8HmrbdfqTHaMjmAGZdKxCmmaojxZfB1WS50k CswPs7272vHZHn7CGZ8pg7V3OX3U9j/zCcwHLN//bN+z/d9K/AigjUAbsAlgS7qZmE0QXQV0AFv5 HIk+57S9Guk1wLWAH9gOBIAu4DpgB7ATuB64AbgR2AXcBNwMBIFu4BZAAmRAAUJAGIgAUaAHiAG9 wK3AbmAP0EfsbCO6HegHmO2pgAbogAGYwAAw6Mz5DqSfBxLAELAPGHbKPu1+UFj/YlXgKy+QtEsU TzbRZHvjoIvmRMqcd7thCNtopFQ8aqUrDXeyJekX2xvF9r5nRe86MSe0exrbmsS2qnz8XGIHNYt3 tO0RvVtIKJUrGV8xZ90mbi0zc87AvnNkjcD4jtCOL5NrFyUHjkmSpEjPh0NSkDxut0Zel7hBaJOk cHS2i5RuqUvq0m6l5Hi2kCneV6ZkeaZcsfIht5J0WUp3JTdBXcMJwx+fqlSL+VQlWyzQQReJ88a+ YimfyjUgU9VK2FSpO6vmBvJXNzZVhV3NSc3V5m2M7ziXcHtpfvvwoUPZ9Mbjh4fpUBWbMb157vD3 qtd+Z277wDGFdDOmS2EtSBHVjAdlSe5Xg6puRKqH40fjVStcbVAePVx95TCVUnm/mc1ZVPbfMB2L 3pjs14r5fLHgakrSUDZdKpaLh6jiHz2SKlkZSg6b5l7NkElJDo0Od+uJRKLrEd/8iF+uftvvHp54 8G/+RHai9IVUaYaur9IW8f6h46Nmv1a+jTZU3f4hGiXTrZepLdSP7Ttn6eEIKYYhBw0pFjAflOPB GLmDEilRKaaFdcmjquGT1uhMeZyGx6PhpDmkbJES16tX+9/YeQvtfp8C8hn65fzcrFhtFl6d/64k zXZJZ+e7zjQ/VaVTEYmerjY9coaEeEdvpEeJyRHSgqZqhINhUnQjqCohpT/YK6kRrRqJb1Oj/R1n btSeuLtsUamcHEzNlJMUn5zUU5VUkhLFdCqXHLMoP5kcL5YyseZuidJzPd3WdKbVk/nWnv5Ald7p NlroG293+h7qFg+OPDa0/qX4X1vPnhd02nRWCD2zde4NuM5sWS+mp/L9VqEyQB1nNozF6U3uTftz aZ2mqi8yZ3quc/Nv1ivvNWw7CGc2+IfTJJ+dWTjjuyYgPCievvld30OtgYD7ptMk+k6v5C0rpH/l JbjDJ77K/N75rT947rmve4yXf/LTh+//+bv/ELbAg/4TBaewDL9H+mfBdsRP4/0/4pKTDT3zUCsr eQovj+L9x8gL/ChitWvp6g+QC4m5YubCmfteR0thuCB4nLdpsh36Zckefsion0zt157sW8578/88 0meng0ijAXueAo36FnMOD+V77Fxt9gIcmAz/XSTuFOCRui95AtcUJwjsHBGrtqf3kTOycPGdh+XZ +bbD4Q0u6nUp5KiXYPn7avjLx7uUdoS6aOCt1VjQpegDHi/Ziqi3JUfZjz9P8UqllJ2YqpDl368e 2JeCAv19/sDYEWiVb0+r4KsEWrzex9RUWRAfk23nLHZv3T+QK06kctuF749OptJCzkx5cmWr+bRW slK+Smoit/nakZLlz1jpXIoa92Y20qmx0lSLakxPeoplq33bmJWfpFyqYulWKSveu/k6bapcKeab s/cf1+bl1w53Pu46accadnTCohUd6465IvoYwbr/OvUoW56FJhyBDOfdS2slIBIS6T3EH0nEA8cQ b7BHAcKIE0zEIpLz1Oe0i3j1TxjRySyinTAsT0LaC2iIUJKYzV2IKgbwG6cHMEoS/GHEG0P43QeO DM4Q7QWX1Rt1OHb8XEujTs5ArhuSJvB0gcPse4rbux+lKbzhmEPepANOywPO+HegrYY9sVrqvIL4 dxsQXW/nr2zUJfJhJ7IVYzHrasffC7wgrDT+fdj9a6P2K5B/hOy49uOitY5fT8wT+rH+k3hy3CrY 7siCX4CV1NM24eJ90AtEPtI+iMFOw0ilun1QwuiIpzCTPLfRLIscMRs/vPc0WkShPbYX2GxZ3TJw iN9hEcHhYXwLNerfZL6jWNiEAAhrrmPcYewOFeOu1NM410wGOdaS7VXW+wQdRV9pXiOBVhN8lsvv zD9b0WOElulnrZpSHI+xpKlxzKDAI+v7MPMkMENl7tvyGE3hnEot8ubtK8ghZuaSG3zdp8Ar8rOw tur11MYl0S44MVfisVDa67QJL9oJgmesXgy/TAoN8kWgbxOjBqFVCVCRU1FuLFpRHI8tddjhK4vS X5mdaFy+PJetvtbKFjSKaICtqAW9MQsy8TCfa9RZ0HCdb/0wK7wS+/lLnf3okJrpwOAzCOJXgmTm ogaZLmNOjSC3tSivoXH9SdCuitzq7GeU2w/bH+PoJQyOCfmY9V5eXtOxBKb5tckq0IZFa+mFFD1o H4NUEW4tJj/JwsiFuS0Z3FoUbttB7ntUXtOWMY5fJvvKst6N2eEuwuUcxDxmeM72e3ZEkMJ7gseA zKKTOA3YPprkerJ9QYz3atvAkszdqDeN0o9bN+zuwC5BtTsQuwIxjYm4rbtR2CgK5EHqReoT6yNC Ivs2fqnYcOXYcqUY8mIKPSNQxyVj5na+JmHwMlifGPd6CnreJF66zcICuxgtirwg1qYiCH5xbf9Q oDXW/4w++XTy4RPJX3W/rD75+uTOv//x7tcYr3YjOYi0yi2nVcDFjDp2Ernd7JPCj+7xkcu9X43/ +10fNbjHswU5+osHnGxIWfc1VjyUSr/4Qx9aoF702S4fedzOly7Ze5WPGt3lSqaYs7550EfraiXB 53zU7B6rfXmwCpU9p3zUhFksuFx0wLg3lZvCfaTjHNqTfdF560/IH/fwCvxTk7V5Cj06TYZGTdQq a63oxa0dsdL3qMVp+cSrmA1vI1BtoKO/Q7DLtsVBvlfYDU9chcFvEFmEanuITSL7omvzt4gu5DpE N347xYZl/TTxTwoC/7Z7Odqr9wWOGaoe0WQ5HIz0qJFgOGpqwZgal4IxXZOUmK7rak98FjfAmiR9 9fq7Zeeg5FCLF7dHqy/g6BotBq3cpFYsVKzpChtJAmu/VSpniwWtmJ9MVbITOSuk9AVCvSFFUdAF KmhDA32BuB43Y7GI2RszjF6tHmweIyqaxEJxWY8YsmED/AGtL6CFNNmIRvUeKWowxEwUtHi/OFgs V/zGdMUqZKySf2/hUPFLLd7Fqct9x9CfokfDUlAze6WgLGtmMGaEQ0FJiktaryxLUiQ+u3u/auyu F3gxr/TZX0N7TSXI3u0frZazKRyd3c2/mHVLF/SC+YF9Txm3aAvTqldvn3Szf/FPa/EuW7/6qh/5 nxH/F7T0vY/97+KkW8+cSLy58cSkh6IvdLrYx7ULvydoPGIs4LEQN5Qv0/Mnkf4LGWudIgAAC/AE AAAAEjRWeD== APPLICATION FOR BREASTFEEDING RESOURCE DIRECTORYINDIVIDUAL PROVIDER OF LACTATION SERVICES LISTINGIn order to list your name in the provider section of the directory, you must be a Certified Lactation Professional, a Licensed Health Practitioner or a La Leche League leader. If your lactation services are free or reimbursed through Medi-Cal, your listing will be free of charge. If there is a fee for any of your services, we charge a listing fee of $100 ($200 if hyperlink to web address is required). This year, you may either:Fill out this form electronically, save it to your computer, and e-mail it (along with credit card information, if fees apply) to louisetlan@earthlink.net. OR you may print the application, fill it out, and then mail or fax the application (along with credit card information or check, if fees apply) to:Louise Arce Tellalian1911 San Ysidro DriveBeverly Hills, CA 90210-1520310-274-2272; Fax 310-859-7077APPLICATIONS MUST BE RECEIVED NO LATER THAN FEBRUARY 1, 2010 FOR INCLUSION IN THE 2010 DIRECTORY. FILL OUT INDIVIDUAL LISTING FORM IN ADDITION.Contact Information: (This information is for office use only and will not be published.)Name: /////wAAAAAUAAUAVABlAHgAdAAxAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT      Mailing Address: /////wAAAAAUAAYAVABlAHgAdAA0ADcAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      City: /////wAAAAAUAAUAVABlAHgAdAAyAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT       State: /////wAAAgAAAAUAVABlAHgAdAAzAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT    Zip code + 4: /////wAABQAAAAUAVABlAHgAdAA0AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT      -/////wAABAAAAAUAVABlAHgAdAA1AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT     Home Phone: (/////wAAAwAAAAUAVABlAHgAdAA2AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT    ) /////wAAAwAAAAUAVABlAHgAdAA4AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT    -/////wAABAAAAAUAVABlAHgAdAA5AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT      Business Phone: (/////wAAAwAAAAUAVABlAHgAdAA2AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT    ) /////wAAAwAAAAUAVABlAHgAdAA4AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT    -/////wAABAAAAAUAVABlAHgAdAA5AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT      Fax: (/////wAAAwAAAAUAVABlAHgAdAA2AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT    ) /////wAAAwAAAAUAVABlAHgAdAA4AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT    -/////wAABAAAAAUAVABlAHgAdAA5AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT      E-mail address: /////wAAAAAUAAYAVABlAHgAdAAxADAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      @/////wAAAAAUAAYAVABlAHgAdAAxADEAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Credit Card Payment (if applicable):Visa /////2UAAAAUAAYAQwBoAGUAYwBrADEAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX Mastercard /////2UAAAAUAAYAQwBoAGUAYwBrADIAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX Card Number: /////wAAAAAUAAYAVABlAHgAdAAxADIAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT       cvv2: /////wAAAAAUAAYAVABlAHgAdAAxADMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT       Exp. date: /////wAAAAAUAAYAVABlAHgAdAAxADQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Name as it appears on credit card: /////wAAAAAUAAYAVABlAHgAdAAxADYAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Billing address if different from above://///wAAAAAUAAYAVABlAHgAdAAxADUAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      City: /////wAAAAAUAAYAVABlAHgAdAAxADcAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT       State: /////wAAAgAAAAYAVABlAHgAdAAxADgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT    Zip code +4: /////wAABQAAAAUAVABlAHgAdAA0AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT      -/////wAABAAAAAUAVABlAHgAdAA1AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT     Professional License/Registration: M.D. /////2UAAAAUAAYAQwBoAGUAYwBrADQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX R.N./////2UAAAAUAAYAQwBoAGUAYwBrADUAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX L.V.N/////2UAAAAUAAYAQwBoAGUAYwBrADYAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX R.D./////2UAAAAUAAYAQwBoAGUAYwBrADcAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX OTR/////2UAAAAUAAYAQwBoAGUAYwBrADgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX PTR/////2UAAAAUAAYAQwBoAGUAYwBrADkAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX Other /////2UAAAAUAAYAQwBoAGUAYwBrADMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX Please Describe: /////wAAAAAUAAYAVABlAHgAdAAxADkAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Professional License/ Registration Number: /////wAAAAAUAAYAVABlAHgAdAAyADAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT       Expiration Date: /////wAAAAAUAAYAVABlAHgAdAAyADEAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Lactation Certification: List type of certification(s) as written on your certificate, e.g. "certified lactation educator", certifying agency, date certificate was issued, and expiration date if applicable.Type of certification: /////wAAAAAUAAYAVABlAHgAdAAyADIAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT       Certification Agency: /////wAAAAAUAAYAVABlAHgAdAAyADMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Date issued: /////wAAAAAUAAYAVABlAHgAdAAyADQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT       Expiration date (if applicable): /////wAAAAAUAAYAVABlAHgAdAAyADUAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      I VERIFY THAT ALL INFORMATION ON MY APPLICATION IS TRUE AND ACCURATEName /////wAAAAAUAAYAVABlAHgAdAAyADYAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT       Date /////wAAAAAUAAYAVABlAHgAdAAyADcAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      PLEASE FILL OUT INDIVIDUAL LISTING FORM THAT FOLLOWS AS WELL.HOW WOULD YOU LIKE TO BE LISTED IN THE DIRECTORY?The directory will list you in your primary service area only and list additional areas served after your name. Please restrict the credentials after your name, and the other services listed, to those relevant to breastfeeding. The number of text lines per listing is limited to six (6), 80 characters/spaces per line. Example: Jane R. Doe, RN, BSN, CLC 818-555-1212000 Main Street, Los Angeles 90000Also serves South Bay Breastfeeding classes, prenatal; consults in office, client's home;breast pump rentals & related sales; free pump delivery; available weekends; Spanish spokenName and credentials (individual and / or business name): /////wAAAAAUAAYAVABlAHgAdAAyADgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Street Address (optional): /////wAAAAAUAAYAVABlAHgAdAAyADkAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      City: /////wAAAAAUAAYAVABlAHgAdAAzADAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT       State: /////wAAAgAAAAYAVABlAHgAdAAzADEAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT    Zip code + 4: /////wAABQAAAAYAVABlAHgAdAAzADIAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      -/////wAABAAAAAYAVABlAHgAdAAzADMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT     Primary service area: /////wAAAAAUAAYAVABlAHgAdAAzADQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Secondary service area: /////wAAAAAUAAYAVABlAHgAdAAzADUAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Contact Phone: (/////wAAAwAAAAYAVABlAHgAdAAzADYAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT     ) /////wAAAwAAAAYAVABlAHgAdAAzADcAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT    -/////wAABAAAAAYAVABlAHgAdAAzADgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Alternate #: (/////wAAAwAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT     ) /////wAAAwAAAAYAVABlAHgAdAAzADcAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT    -/////wAABAAAAAYAVABlAHgAdAAzADgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT     Services offered: Keep my listing the same as last year /////2UAAAAUAAcAQwBoAGUAYwBrADMANwAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX OR check all that apply below:Breastfeeding Classes: Group Prenatal /////wEAAAAUAAcAQwBoAGUAYwBrADEAMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX Group Post partum /////wEAAAAUAAcAQwBoAGUAYwBrADEAMQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX Private Instruction/////2UAAAAUAAcAQwBoAGUAYwBrADEAMgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX Other/////2UAAAAUAAcAQwBoAGUAYwBrADEAMwAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX Please Describe: /////wAAAAAUAAYAVABlAHgAdAAzADkAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Consults: In client's home /////2UAAAAUAAcAQwBoAGUAYwBrADEANAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX Your office /////2UAAAAUAAcAQwBoAGUAYwBrADEANQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX Hospital inpatient /////2UAAAAUAAcAQwBoAGUAYwBrADEANgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX In pediatric office/////2UAAAAUAAcAQwBoAGUAYwBrADEANwAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX WIC center /////2UAAAAUAAcAQwBoAGUAYwBrADEAOAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX Hospital clinic /////2UAAAAUAAcAQwBoAGUAYwBrADEAOQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX Other /////2UAAAAUAAcAQwBoAGUAYwBrADIAMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX Please Describe: /////wAAAAAUAAYAVABlAHgAdAAzADkAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Breast pump: Purchase /////2UAAAAUAAcAQwBoAGUAYwBrADIAMQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX Rentals /////2UAAAAUAAcAQwBoAGUAYwBrADIAMgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX Related sales /////2UAAAAUAAcAQwBoAGUAYwBrADIAMwAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX Pump delivery /////2UAAAAUAAcAQwBoAGUAYwBrADIANAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX Special breastfeeding services: (teens, developmentally disabled, hearing impaired, support groups) /////wAAAAAUAAYAVABlAHgAdAA0ADAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Do you accept credit cards? Yes /////2UAAAAUAAcAQwBoAGUAYwBrADIANQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX No /////2UAAAAUAAcAQwBoAGUAYwBrADIANgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX Do you wish to have a live hyperlink included in the on-line edition? ($100 extra) Yes /////2UAAAAUAAcAQwBoAGUAYwBrADIANwAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX No /////2UAAAAUAAcAQwBoAGUAYwBrADIAOAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX Do you provide free or Medi-Cal reimbursable services? /////2UAAAAUAAcAQwBoAGUAYwBrADMAMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX In what languages do you provide services? /////wAAAAAUAAYAVABlAHgAdAA0ADEAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Are services provided on weekends? Yes /////2UAAAAUAAcAQwBoAGUAYwBrADMAMQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX No/////2UAAAAUAAcAQwBoAGUAYwBrADMAMgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX /////wAAAAAUAAYAVABlAHgAdAA0ADIAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Are services provided during the evenings? Yes /////2UAAAAUAAcAQwBoAGUAYwBrADMAMQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX No/////2UAAAAUAAcAQwBoAGUAYwBrADMAMgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX /////wAAAAAUAAYAVABlAHgAdAA0ADMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      If you would like to add something unique, describe here: /////wAAAAAUAAYAVABlAHgAdAA0ADYAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Review your listing to make sure it meets the space limitations stated above.DID YOU FILL OUT THE INDIVIDUAL APPLICATION FORM? FILL OUT AND MAIL QUESTIONNAIRE WITH APPLICATION.PLEASE SUBMIT THE FOLLOWING QUESTIONNAIRE TO:Louise Arce Tellalian1911 San Ysidro DriveBeverly Hills, CA 90210-1520310-274-2272; Fax 310-859-70771. Your name: /////wAAAAAUAAYAVABlAHgAdAA0ADQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      2. Do you wish to be kept on Directory application mailing list? Yes/////2UAAAAUAAcAQwBoAGUAYwBrADMAMwAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX No /////2UAAAAUAAcAQwBoAGUAYwBrADMANAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX 3. Are you listing yourself as a lactation provider for 2010? Yes /////2UAAAAUAAcAQwBoAGUAYwBrADMANQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX No /////2UAAAAUAAcAQwBoAGUAYwBrADMANgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX Reason: /////wAAAAAUAAYAVABlAHgAdAA0ADUAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      4. Do you know of any other lactation professional that would be interested in receiving this mailing? If so, please provide their:Name: /////wAAAAAUAAUAVABlAHgAdAAxAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT      Mailing Address: /////wAAAAAUAAYAVABlAHgAdAA0ADgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      City: /////wAAAAAUAAUAVABlAHgAdAAyAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT       State: /////wAAAgAAAAUAVABlAHgAdAAzAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT    Zip code + 4: /////wAABQAAAAUAVABlAHgAdAA0AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT      -/////wAABAAAAAUAVABlAHgAdAA1AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT     Phone Number: (/////wAAAwAAAAYAVABlAHgAdAA0ADkAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT    ) /////wAAAwAAAAYAVABlAHgAdAA1ADAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT    -/////wAABAAAAAYAVABlAHgAdAA1ADEAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT     E-mail address: /////wAAAAAUAAYAVABlAHgAdAAxADAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      @/////wAAAAAUAAYAVABlAHgAdAAxADEAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Breastfeeding Task Force of Greater Los Angeles Resource Directory - 2010 Individual Application