NP/APN Network Membership Form

Title

First*

Middle

Last*

Job Position

Address

Address 2

City/Town

ZIP/Postal Code

Country*

Telephone

Email*

If a member of an ICN National Nurses Association (NNA), please provide name of association and membership number. (You do not need to be a member of an ICN NNA to be a network member)

Name Of Association

Member Number

What network activity would you be willing to be involved in?

Planning network conferences/meetings

Developing sponsorship/fundraising

Education

Research

Regulation