First Name:
Last Name:
Address:
City:
State:
County:
Zip:
Phone:
Pager/Cell:
Email:
Employer:
Work Status:
Full Time: Part Time: Retired:
Fax:
Michigan RN License #:
State House:
State Senate:
Congressional:
Name of PNP Program Attended:
Year Graduated:
Education:
AD: BSN: MSN: Diploma: Other:
Areas of Clinical Expertise :
Other Memberships:
Certifications:National Board PNP/A ANCC: Other:
Previous member of Michigan NAPNAP:
Yes:
How many years have you been a member:
Do you wish to be included on published mailing lists:
Are you a member of National NAPNAP: