The NC Chapter of NAPNAP

NCNAPNAP Registration Form (part 1 of 2)

*Full Name:
Address:	City:	State:
Zip Code:	*E-mail:
Day Ph#:	Work Ph#:	Cell Ph.#:
Are you registering as a(n):
1. Would you like to be included in our Directory: Yes No
- If yes, which number would you like published:
2. May other nurse practitioners call you for consults? Yes No
3. Are you a member of the national NAPNAP organization? Yes No
- Member #
4. Are you interested in running for an office in our state chapter? Yes No
- If yes, which ones?
5. Are you interested in serving on a state committee? Yes No
- If yes which ones?
6. Would you be willing to give a presentation in your area of expertise to professional or community groups? Yes No
7. Job Description:
8. List some ideas that you would like to see our state chapter address:
9. I work:
10. Professional Status:
11. Are you certified? Yes No
- if yes, which organization?
12. Position:
13. Practice Setting:
14. Area of expertise:
15. If you have been published please list:
16. Any community involvement/recognition? Yes No
17. Have you served in any elected office? Yes No
- If yes, what office and when?
*Create a username:
*Please create a password:
*Reconfirm password:
Dues
$30.00/year, due each Sept. 1
$25.00/year, due each Sept. 1 - (Students only)

Please enter your last name.		*Required Fields

NCNAPNAP Registration Form (part 2 of 2)

Please click below:

Students
Please click below:

NCNAPNAP
101 Thomas Lane, #E-1
Carrboro, NC 27510-1362
mwatral@nc.rr.com



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