IOWA ASSOCIATION OF NURSE PRACTITIONERS MEMBERSHIP APPLICATION FORM

Membership year July 1-June 30

Date: ______________                                                                                             New______ Renewal ______                           NAPNAP Membership:

Mother's Maiden Name __________________                                         Current___          Not a member___

Name:__________________________________________ Phone:_______________/_________________

                                                                                                                        Home                       Work

Home address:_________________________________________________________________________

                            Street                                                            City                                 State                  Zip

County: ________                                                                                                                                                 Legislative District Senate: ________ House: _______

                                                                                                                                                                                                                                                                             (Check your voter registration card for #)

Place of Employment:___________________________________________________________________

                                    Street                                                    City                                    State                Zip

E-mail: ___________________________________________ FAX #: ___________________________

 

1. Special interests (i.e. abuse, diabetes):

Would you be interested in being part of the speaker’s bureau? Yes ___ No ___

2. Practitioner status: PNP____ ANP ____ FNP _____ Women’s Health Care (specify) _____________

                                                                                                 School NP______ Geriatric NP_______ Other (specify)______________________________

3. Licensed as ARNP in Iowa: Yes___ No___

4. Certified? Yes _____by whom____________________________ No _____ Student_____________

5. Actively employed as NP? Yes ____   Full-time_____ Part-time_____ No ____

6. Committees you wish to participate on:

Affiliation______   Membership______      By-Laws_______   Nominations______

Newsletter_____   Public Relations _____   Legislature______ Continuing Ed______

7. Office you are interested in: _____________________________________

8. Interested in being a preceptor? Yes __ No __

9. Professional organizations you are a member of: _____________________________

10. Special awards/achievements: _______________________________________________________

11. Name on mailing list for recruiters/educators: Yes __No __                                e-mail tree: Yes __ No __

                                                                                                                                                                                            Name on list serve: Yes __No __

 

                                    Return to:    Kathy Ruppenkamp                                                                           Active member: $85

                                                        3376 Hwy 1 SW                                                                               Associate member: $60
                                                        Iowa City, IA 52240                                                                          Student fee: $35
                                                                                                                                                                  Retiree: $35

 

12. Make checks payable to: IANP                                                                   Additional contributions for lobbying efforts

                        Amount enclosed: $__________                                                             would be greatly appreciated.

                                                                                                                                                (Your IANP membership fee is not tax-

                                                                                                                                                deductible due to our lobbying efforts.)