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International Association of Sickle Cell Nurses And Physician Assistants |
(please type or print in ink)
Date:
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Name:
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Home Address:
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Home Phone:
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Work Address:
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Institutional Affiliation:
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Position:
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E-mail Address:
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Work Phone/FAX:
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Preferred mailing address:
[__] Home [__] Office
Enclosed is my check for:
[__] $65 (Full Member) [__] $35
(Associate) [__] $50 (Charter)
[__] $0 (Affiliate: STAC)
Check one:
[__] New [__] Renewal
Please note:
Dues Payable Annually on March 1 in US Dollars Only.
New members pay a pro-rated amount depending on which month they join.
RNs and PAs are not eligible for Associate Memberships.
| Print and mail this application to: |
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IASCNAPA c/o Jane Hennessy, RNCNP, MPH Hematology/Oncology Clinic, Suite 4150 2525 Chicago Ave. South Minneapolis, MN 55404 |