(Please print)

Name: _____________________________________________     Date:  ___________________

Circle one:       ARNP      CNS      CNM      CRNA      Student

Directions: Applicants who were not registered in 2008 must complete entire form.

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:
      

 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.