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If you have
questions on directory application, please contact Louise at
ltellalian@BreastfeedLA.org or call 310-274-2272.
If you experience technical difficulty, please contact Amy at
ama@BreastfeedLA.org or call
760-929-0325 ext. 20.
It is very important that
all the required fields are completed. Incomplete application will
not be processed or listed. You can either select to pay by credit
card online or mail in check payment upon completing your
application.
$150 Basic:
Listing in the printed Resource Directory
and on the Task Force website.
$200 Basic plus
Hyperlink: Listing in the printed Resource Directory,
on the Task Force website and your email and/or website hyperlinked on the Task
Force website.
Please review individual listing format in the
2007
Directory on-line (this will open another
window).
Personal Information: |
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Last Name:
MI:
First Name:
Salutation: |
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| Business Name:
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Business Phone Number: --Ext.
Business Fax Number: -- |
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Home Phone Number:--
E-Mail: |
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| Address 1:
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| Address 2: |
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City: State:
Zip:
-
zipcode+4 look up |
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| Is this your first application to the Directory?
Yes
No |
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| If No, when did you
last apply? (mm/dd/year) |
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| Credentials: |
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| List your qualifying credentials: |
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LVN
RN
MD
OT
PT
RD
Other:
Note: Please check the box "Other" if
you don't have any credentials. |
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| License Number:
Expiration Date: (mm/dd/year) |
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| Lactation Certification: |
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IBCLC
Certified
Lactation Consultant
Certified
Lactation Educator
Certified
Lactation Counselor
Other:
Note: Please check the box "Other"
if you don't have any credentials. |
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| Organization that issued certification:
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| Certification Date:
(mm/dd/year) |
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| Expiration Date:
(mm/dd/year) |
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| Please verify the information,
then click next to continue. |
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Directory Information:
This information will be used to compile your listing in the
2008 Directory. Please look at the individual listing format in the
2007
Directory online (this will open another
window).
If you were listed in 2007,
may we use the EXACT same listing?
Yes
/
No
If you were NOT LISTED in 2007, or if you would like to make CHANGES to your 2007 listing, please complete the fields below.
You are limited to six
lines of text
with 80 spaces on each
line. Please restrict
your credentials and services to those relevant to lactation.
You will be listed under the heading in your primary service area.
If you wish, your secondary areas will be named as part of your
listing. Entering your home address is optional.
$150 Basic:
Listing in the printed Resource Directory
and on the Task Force website.
$200 Basic plus
Hyperlink: Listing in the printed Resource Directory,
on the Task Force website and your email and/or website hyperlinked on the Task
Force website.
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| Business Name and/or Individual Name and
Credentials:
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| Name and credentials of lactation
practitioner if not listed in above:
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| Phone:
-- |
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| Address1:
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| Address2:
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| City:
State:
Zip:
-
zipcode+4 look up |
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| Primary Service Area:
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Additional Service Area:
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| Services Offered: (Check all that apply) |
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| Prenatal Group Classes
Post Partum Group ClassesPrivate Instruction |
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| Consultations: |
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In Hospital
In Client's Home
In Your Office
In Pediatric Office
In WIC Center
In Hospital Clinic
Other
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| Breast Pump: |
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| Sales
Rental
Pump Parts
Breast Feeding Supplies
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| Special Breastfeeding Services
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| Do you accept credit cards?
Yes
No |
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| Do you have a web site?
Yes
No If Yes,
web address: |
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| Do you provide
Free Services
MediCal Reimbursable Services |
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Do you offer service in language's other then English?
Yes
No
If Yes, what language(s):
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| Do you provide services on
Saturday
Sunday
Evenings |
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If you provide free, Medi-Cal reimbursable, or very low cost
services, you may have a FREE listing in the Free and Medi-Cal
listings of the Directory.
If you charge for your services, you will be listed in the fee based Providers of Lactation Services section of the Directory and need to pay the $150.00 subscription fee.
You may have your website or email address hyperlinked in the online version of the Directory for an additional $50.00.
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| Please verify the information. |
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| Please select
the payment amount then select the payment type. |
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$150 Basic:
Listing in the printed Resource Directory
and on the Task Force website.
$200 Basic plus Hyperlink: Listing in the printed Resource Directory,
on the Task Force website and your email and/or website hyperlinked on the Task
Force website. |
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| Payment Information: |
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| Name as appears on credit card
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| Billing Address
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| City
State
Zip
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zipcode+4 look up |
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| Card Type*:
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| Card
Number*:
No spaces or dashes. |
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Card verification number (CVV2):
*Required if it's on your card. (Help locating number) |
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| Expiration Date*:
Month:
Year:
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Please type in your name:
By typing my name here, I certify that all the above information is true and valid.
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Mail Check Information: |
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| Make check payable to :
Breastfeeding Task Force of
Greater Los Angeles |
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| Mail check to:
Louise Arce Tellalian
1911 San Ysidro Drive
Beverly Hills, CA 90210-1520
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Please type in your name:
By typing my name here, I certify that all the above information is true and valid.
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