Membership

Dues

Annual membership dues are collected from April through June 30th. The fee is $30 for APNs and $20 for student members! The membership form can be copied or downloaded from this website or pasted into a Word Document. (Click here to download form.)

Please print clearly or type information. Completed membership forms and fees may be forwarded to Barb Chavez, Treasurer at the SNAP PO Box 11496, Merrillville, IN 46411-1496

SNAP MEMBERSHIP FORM

Date:__________

Name:____________________________________________________

Home Address:____________________________________________

City:________________________ State: ___________ ZIP:_________

Practice Name: ____________________________________________

Office Address: ____________________________________________

City:________________________ State: ___________ ZIP:_________

Specialty: _____________________Office Hours:________________

Phone: H_____________________ W________________________

Email:____________________________________________________

Education:________________________________________________

Certification: ANCC_________ AANP_________ OTHER_________

On which committee will you serve?

_____ Membership	_____ Programs
_____ Newsletter	_____ Nominating
_____ Publicity	_____ Annual CEU Program
_____ Grant Writing

Will you be willing to be a preceptor for NP/CNS students? ___Yes ___No

Membership is from July 01, 2011 to June 30, 2012

Dues: APN $30.00
MS/MSN Student $20.00

Mail to: SNAP
P.O. Box 11496
Merrillville , IN 46411-1496