Date of Application: -- mm/dd/yy
 
New Membership Renewal
 
Contact information:
Name:
Nursing Credentials:
Street Address:
Address (cont.):
City:
State/Province:
Zip/Postal Code:
Business Name or Employer:
Work Phone:
Cellular Phone:
Home Phone:
FAX:
E-mail:
   
Membership Renewals: Please note: Non-payment of dues 60 days after
renewal notice results in removal from membership list.
Chapter renewal date:
-- mm/dd/yy
National member ID number:
National renewal date:
-- mm/dd/yy
 
If new to the National Organization (AALNC) with no member ID number as yet,
please indicate date of application to national:
-- mm/dd/yy

New Members: Choose one of the following membership categories:

Active Membership $50

Active membership in the Chapter may be granted to any registered nurse who maintains active licensure in the US or its possessions who currently provides consultation on healthcare issues within the legal arena.  Active members may vote, hold office, serve on committees, and partake of all other benefits of membership as may determined from time to time by the Board of Directors.  Active members must hold current membership in the national organization, the American Association of Legal Nurse Consultants.


Associate $50

Associate membership in the Chapter may be granted to registered nurses maintaining active licensure in the US or its possessions who have an interest in the medical/legal issues.  Associate members must hold current membership in the national organization, the American Association of Legal Nurse Consultants.


Sustaining $75

Sustaining membership may be granted to individuals or groups with an interest in the goals and activities of the Chapter.  Sustaining members must hold current membership in the national organization, the American Association of Legal Nurse Consultants.

   
Clinical Specialties:
Other Nursing Affiliations:
FL License Number (for CEUs):
Current State(s) Licensed in:
Date of Birth:
Degree(s)/Date(s) Graduated:
Current Area of Medical-Legal Practice:
 
Committee Interest: Active category members are encouraged to serve on committees.
Please indicate those in which you are interested:

 
Continuing Education Membership Social/Hospitality
Publications Conference Scholarship
Program    
 


Pay Your Membership Dues