NAME_____________________________________ DATE_________
ADDRESS________________________________________________
CITY_______________________ STATE____ ZIP_______________
HOME PHONE (____)_______________ HOME E-MAIL______________________
WORK PHONE (____)_______________ WORK E-MAIL______________________
CERTIFICATION STATUS: Please check which ever applies to you.
PNCB____ ANCC as PNP_____ ANCC as FNP_____ Other ________
Do you wish to be notified of legislative issues by e-mail? ( ) yes ( ) no
May we list your e-mail/address/phone on the Chapter Membership Directory shared with members only? ( ) yes ( ) no
CHAPTER NEWSLETTER WILL BE SENT BY E-MAIL*
*If more than one e-mail please indicated which one: ________________________________
Membership Year: March 1 to February 28
Associate members are any nurse practitioners who are active in state chapter and interested in fostering the objectives of the association. They can also be RNs, CNS, etc., who are not eligible for certification. Associated members may serve on committees but do not have voting privileges.
Active members are active in the state chapter and paid members of the national organization. They are either certified as a nurse practitioner, eligible for certification, or trained prior to 1971. Active members have voting privileges, may serve on committees, and hold office.
Please indicate type of membership below:
( ) NEW ( ) RENEWAL ASSOCIATE—State chapter only member $25.00
( ) NEW ( ) RENEWAL ACTIVE--National and State member $25.00 plus membership paid to national NAPNAP (separate application @ www.napnap.org)
( ) ARNP Student---Membership fee waived
( ) LATE FEE after May 1 $ 5.00 TOTAL___________
MAKE CHECK PAYABLE TO: Washington State Chapter of NAPNAP
Mail to:
Karen L. Fitzgerald
2220 Simmons St Unit A
Dupont, WA 98327
Indicate any committees on which you are willing to work or want more information on:
___budget ___by-laws ___nominations ___membership ___legislative ___newsletter ___public relations ___continuing ed. ___child advocacy
For Membership use: _______Check received _______Check to treasurer _______Address checked _______Database updated ________e-mailed Receipt