SNAP MEMBERSHIP FORM
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SNAP MEMBERSHIP FORM
Date:__________
Name:____________________________________ Title: _________
Home address:__________________________________________________
City:____________________ State: ____________ ZIP:_________
Practice Name: __________________________________________________
Office Address: _______________________________________________
City: ______________________________ State: _______________ ZIP: _________
Specialty: ______________________ _____ Office Hours: _____________________
Phone: Cell:___________________Home: ________________________
Email:____________________________________________________
Education:_________________________________________________
Certification: ANCC_________ AANP_________ OTHER_________
On which committee will you serve? ___ Membership ___ Programs
___ Newsletter ___ Nominating
___ Publicity ___ Annual CEU program
Are you be willing to be a preceptor for APN students? ___Yes ___No
Membership is from July 01 to June 30th annually
Dues: APN $30.00 Mail to: SNAP
APN Student $20.00 P.O. Box 11496
Merrillville, IN 46411-1496
Pay online at
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