Virginia: Hampton Roads Chapter

National Association of Pediatric Nurse Practitioners
Chapter Membership Application

Make checks payable to:  HRAPNAP    (Electronic Bill Payment Services Accepted)
Mail to: PO Box 2631  Norfolk, VA 23501-2631     Voice & Fax:  (757) 455-5238

                              *** Please Print ***

Full Name (Including  Credentials)  _________________________________

Address ________________________________________________________

City _______________________   State ______   Zip (Plus 4) _______-______

Home Phone (____) _____-_________  

Work Phone (____) ______-_________ Ext __________

Pager (_____) _____-_______   Fax (_____) _____-_______

E-Mail _____________________________________________  

I DO ____    DO NOT ____   wish to join the local email listserver for chapter news.

Current  Workplace _______________________________________________

Work  Address ___________________________________________________

                        ___________________________________________________

Specialty _______________________________________________________

 Mother's Maiden Name ________  Date of Birth ____/____ (Month and Day only)

(This information is required by NAPNAP, until alternative methods are developed to assure that members are appropriately identified from year to year, even during years that membership is not maintained or times when names change, we must have this information.  It will be kept in the strictest confidence and not distributed.)

Nick Name _____________________________

Credentials:

BSN __    MSN __    PhD __    DScN __     BS __    
MS __   ANCC __   NCBPNP/N __ Other _________

NAPNAP Membership Number  ___________________

(Enclose a copy of your NAPNAP card for the discounted dues rate.)

Dues (October 1 to September 30)
NAPNAP Members:  Active $30 __         Associate $30 __         Student $15 __
Non-NAPNAP Members:  Active $40 __         Associate $40 __         Student $20 __
(Students must enclose a letter from their school indicating enrollment.)