Membership

Dues

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

Date:__________

Name:____________________________________________________

Title: ____________________________________________________

Home Address:____________________________________________

City:________________________ State: ___________ ZIP:_________

Practice Name: ____________________________________________

Office Address: ____________________________________________

City:________________________ State: ___________ ZIP:________

Specialty: _____________________Office Hours:________________

Phone: Cell: _____________________ Home ___________________

Email:____________________________________________________

Education:________________________________________________

Certification: ANCC_________ AANP_________ OTHER_________

On which committee will you serve?

_____ Membership	_____ Programs
_____ Newsletter	_____ Nominating
_____ Publicity	_____ 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 $50.00
APN Student $30.00

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