Hanp.org: Membership Application


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MEMBERSHIP APPLICATION

Annual membership runs from September 1 to August 31 of the following year. You can also download Membership Application form here in PDF.

I would like to be a member of the Houston Area Nurse Practitioners.

I am:

Renewing my existing membership ($35)
A new member ($35)
A student member ($20)

Descriptive text for Full or Associate goes here

I am applying for:

Full Membership
Associate Membership

Make checks payable to HANP and mail to P.O. Box 272766, Houston, TX 77277-2766

or

Make payment using PayPal (You are not required to have a PayPal account to use a credit card through PayPal) We have just instituted using PayPal. If you have problems, please let us know via our sites feedback form.

Click the box below - make payment online using PayPal
Complete form below
Click Submit your application. This will take you to the PayPal site

Make Payment online using

First Name:

Last Name:

Credentials:

Example: RN, MS, FNP-C

Street Address:

City:

State:

Zip Code:

Home Phone #:

Cell Phone #:

Pager #:

Email Address:

Birth Date:

m/d/yyyy

RN License/ Certificate Number:

Password:

Must be at least 6 characters

ReType Password:

Work Information

Work Place:

Work Address:

Work City:

State:

Work Zip Code:

Work Phone:

Work Fax:

Work Email:

Demographic Data

Primary Specialty Area:

Secondary Specialty Area:

Practice Area:

Student Office Practice with MD Clinic	Private Practice School of Nursing Home Health	LTC Hospital Administration
HMO School Nurse Nsg home/ Ex Care Facility

Highest Degree:

Certification	Baccaalaureate	Masters
Post Masters	PhD	DSN
EdD	MD/DO	ADN
DNP

Certification:

None	ANCC	PNCB
AANP	WHNP	ACC
CCNA	NAPNAP	AAPA
AMA	Other

Salary:

Less than $45,000	$45,000 - $50,000
$50,001 - $55,000	$55,001 - $60,000
$60,001 - $65,000	$65,001 - $70,000
$70,001 - $75,000	$75,000 - $80,000
$80,001 - $85,000	$85,001 - $90,000
$90,001 - $95,000	$95,001 - $100,000
$100,001 - $105,000	$105,001 - $110,000
Greater than $110,000

Date Paid:

Check #:

Amount:

A new member or renewing member ($35)
A student member ($20)
(Full/Associate: $35 / Student: $20)