Annual membership dues are collected from the Annual Pharmacology CE event through June 30th.
The membership form can also 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 the Treasurer at the SNAP PO Box 11496, Merrillville, IN 46411-1496
SNAP MEMBERSHIP FORM
City:________________________ State: ___________ ZIP:_________
Practice Name: ____________________________________________
Office Address: ____________________________________________
City:________________________ State: ___________ ZIP:________
Specialty: _____________________Office Hours:________________
Phone: Cell: _____________________ Home ___________________
Certification: ANCC_________ AANP_________ OTHER_________
On which committee will you serve?
||_____ Annual CEU Program
Will you be willing to be a preceptor for APN students? ___Yes ___No
Membership is from July 01 to June 30th annually.
Dues: APN $30.00
APN Student $20.00
Mail to: SNAP
P.O. Box 11496
Merrillville , IN 46411-1496