NORTH CENTRAL FLORIDA ADVANCED PRACTICE
NURSES, INC.
MEMBERSHIP DATA FOR JANUARY 1, 2008-DECEMBER
31, 2008
(Please print)
Name: _____________________________________________ Date: ___________________
Circle one: ARNP CNS CNM CRNA Student
Directions: Applicants who were not registered in 2007 must complete entire form.
Members returning from 2007,
ENTER CHANGES in sections A, B, C as indicated.
SECTION A
___ Information unchanged from 2007
Mailing Address: ______________________________________________________________________
City/State: _____________________________ Zip ____________ Home Phone #: __________________
E-mail Address: ________________________________________________________
SECTION B
___ Information unchanged from 2007
Practice:_______________________________________ Specialty: _____________________________________
Address: _________________________________________________________________________________________
Telephone: _____________________________ Can you accept referrals? ____Yes ____ No
SECTION C
___ Information unchanged from 2007
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, 2008-DECEMBER 31, 2008. 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: Karyn Wagner, ARNP; P.O. Box 358801, Gainesville, FL 32635-8801
E-mail: wagnek@shands.ufl.edu
Thank you for your participation in promoting Advanced Practice Nurses in our region.