NORTH CENTRAL FLORIDA ADVANCED PRACTICE NURSES, INC.
MEMBERSHIP DATA FOR JANUARY 1, 2010-DECEMBER 31, 2010

(Please print)

Name: _____________________________________________ Date: ___________________

Circle one:
ARNP CNS CNM CRNA Student

Directions: Applicants who were not registered in 2008 must complete entire form.
Members returning from 2009, ENTER CHANGES in sections A, B, C as indicated.
SECTION A

___ Information unchanged from 2009

Mailing Address: ______________________________________________________________________

City/State: _____________________________ Zip ____________ Home Phone #: __________________
E-mail Address: ________________________________________________________

SECTION B

___ Information unchanged from 2009

Practice:_______________________________________ Specialty: _____________________________________

Address: _________________________________________________________________________________________
Telephone: _____________________________  Can you accept referrals?   ____Yes   ____ No

SECTION C


___ Information unchanged from 2009

GENERAL INFORMATION:
1. Do you have certification?     ____ Yes      ____ No

If yes, in what area? ___________________ If yes, with whom?_________________________

2. Are you currently a preceptor? ___ Yes ____ No

Are you interested being a preceptor for an ARNP student? ____ Yes ____No

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Membership dues for JANUARY 1, 2010-DECEMBER 31, 2010. Please check one:
      
ARNP/CNS/CNM/CRNA
Student membership (limited to those graduating within 6 mos.)
___: $30 FNA member
___: $10 FNA member
___: $40 non-FNA member
___: $20 non-FNA member

Please note: NCFAPN dues are not tax deductible.

Please make check payable to: North Florida Advanced Practice Nurses, Inc.
Return to: Paula Turpening, Secretary; 9331 SW 19th Avenue; Gainesville, FL 32607
E-mail: turpepc@shands.ufl.edu

Thank you for your participation in promoting Advanced Practice Nurses in our region.