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Registration Form

Last Name
First Name
E-mail Address
Mailing Address
City
Postal Code
Home Phone
Work Phone
I wish my contact information to be released to the College of Nursing Education, College of Medical Education (Division of Continuing Profession Learning) and College of Pharmacy/ Nutrition for notification of upcoming educational venues.
I am RN(NP)
Year of initial licensure
RN practicing in expanded practice.

Area(s) of Employment

Clinical Clinical
Primary Care
Full Time
Part Time (indicate your hours per week below)
hours/week
Urban
Rural
Remote
Acute Care Acute Care
Area of Specialty
Patient Population
Teaching Teaching
hours/week teaching NP practice
Research Research
hours/week spent researching NP practice
Administration Administration
hours/week spent managing NP practice
Unemployed Unemployed
Primary Place of Employment
Additional Places of Employment

Other Information

What is your NP educational preparation?
Years of NP Experience
I am interested in being a preceptor for NP students. My contact information can be shared with U of S and SIAST programs.
I am interested in being a mentor for other RN(NP)s
For educational programming what educational topics would be of interest to you?
Which political or other issues would you like to see addressed through NPOS?
I am interested in sitting on the NPOS executive or a committee.
Other suggestions for involvement:
Do you have an area of expertise that you would like to share with the group?
I am available for consultation on this topic to my colleagues.
I would be pleased to offer an educational group session on the above topic.
Do you have any suggestions on how NPOS can better serve its members?
Include CAAPN Fees?

Paypal Receipt #
Date of Membership Purchase
Registration Type

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