NPGS Membership Application - Gonzaga University

Membership Application
2008-2009

2008-09 Membership Dues:
Professional: $100
Students: $25 - use STUDENT discount code on this form.
A percentage of your dues go to support nurse practitioner political/lobbyist groups.
The membership year is August 1 to July 31 each year. Fees are accepted at anytime within the year and apply to the current year only.

To become a Nurse Practitioner Group of Spokane Member, please fill out the form below:

This information is for NPGS records only. Please note, failure to provide complete information may result in you missing important information and updates.

Please pay special attention to the accuracy of your e-mail address. A confirmation e-mail with payment instructions will be sent via email.

The NPGS website has a web directory of providers. You must be able to see patients to be listed. Only those who meet the requirements and indicate here that they want to be listed will be included. You must provide your complete information to be listed.

Price: $100.00

Discount Code (if any):

First Name: *

Middle Name:

Last Name: *

Address Line 1:

Address Line 2:

City:

State:

Zipcode:

Home Phone (If outside the US, please use the country code): - () -

E-mail Address: *

Employer:

Specialty:

Congressional district:

Legislative district :

Include me on the NPGS Web Directory:

Add me to NPGS Listserv:

Publish my information in the membership list:

Comments:

Do Not Edit:

Do Not Edit:

This information is for NPGS records only. Please note, failure to provide complete information may result in you missing important information and updates. Please pay special attention to the accuracy of your e-mail address. A confirmation e-mail with payment instructions will be sent via email. The NPGS website has a web directory of providers. You must be able to see patients to be listed. Only those who meet the requirements and indicate here that they want to be listed will be included. You must provide your complete information to be listed.

Price:	$100.00
Discount Code (if any):
First Name:	*
Middle Name:
Last Name:	*
Address Line 1:
Address Line 2:
City:
State:
Zipcode:
Home Phone (If outside the US, please use the country code):	- () -
E-mail Address:	*
Employer:
Specialty:
Congressional district:
Legislative district :
Include me on the NPGS Web Directory:
Add me to NPGS Listserv:
Publish my information in the membership list:
Comments:


Do Not Edit:
Do Not Edit: