NONPF APPLICATION FOR PROGRAM (GROUP) MEMBERSHIP
Membership Year: September 1-August 31

Name of Program:___________________________________________________________________________

Director of Program:_________________________________________________________________________

Program Address:___________________________________________________________________________

_________________________________________________________________________________________

City:_______________________________________ State:___________  Zip:___________________________

Program Phone #:_____________________________ Fax:___________________________________________ 

Location of Program (Select one): 

	School of Nursing	School of Medicine	Other:______________________________________

Does your institution have an Academic Nursing Center?	Yes   No

Name 4 faculty members to be covered by group membership fee ($500.00) 

Please include individual profile forms for each group member: 

1. ___________________________________________  3.___________________________________________

2. ___________________________________________  4.___________________________________________

Names of additional faculty to be covered by $100 per person: 

5. ___________________________________________  7.___________________________________________

6. ___________________________________________  8.___________________________________________

SIG Membership (Optional): Members may join one or more of the special interest groups (SIGs) to engage in targeted discussion and activities with other faculty.  Additional membership fee of $15 per SIG per faculty member.  Please identify the corresponding letter of the SIG by the name of any faculty member above who wished to join a SIG.

Academic Nursing Center - N;  Acute Care - A;  Distance Learning - D;  Gerontological - G;  International - I;  Program Director - Y;

Psych-Mental Health - P;  End of Life Care - E ; Research - R

Additional SIG Payment:_____________________

Amount enclosed:_____________________

Make checks payable to NONPF and return to the following address:

NONPF

1522 K Street, NW, Suite 702

Washington, DC  20005

Program membership is available to all nurse practitioner educational programs.  Each nurse faculty member for whom dues are paid under the program membership shall have one vote, is eligible to hold an elected position, receives membership communications, and receives membership discounts.

Please have each faculty member complete a profile form and include with this form.