Docstoc

Atlanta

Document Sample
Atlanta Powered By Docstoc
					                                                       ATLANTA



Mail completed application, check, copy of RN license and copy of national card to :

Cheryl Cusimano           or Fax: 770-783-2265 or
152 Rebel Ridge           or Email via PDF: Cheryl@care-cap.com
Dallas, GA 30132

The deadline for renewal is January 31, 2012.
There is a late fee of $10 for those renewing their membership after January 31, 2012.
If renewing by mail, please ensure your payment is postmarked by the deadline


                                          GENERAL INFORMATION

Last Name: _________________________ First Name: _________________________Middle Initial: ___

Credentials: (e.g., BSN, RN, CEN):________________________________________________________

Name of Employer/Business: ____________________________________________________________

Preferred Mailing Address:        Home             Business

(You can list both addresses below; just let us know which is preferred)

Home Address: _____________________________________________________________________________

City:_______________________________________ State:__________ Zip:______________________

Business Address: _____________________________________________________________________________

City:_______________________________________ State:__________ Zip:______________________

Telephone: (Only give phone numbers you wish to be contacted at)
Preferred Phone Number:           Home              Work             Cell
Secondary Preferred Phone Number:              Home           Work          Cell
Cell: ____________________ Home: _____________________ Work: __________________________
Fax: __________________________________
Preferred Email:        Home               Work             (You can list both emails below, just let us know which is preferred )

Home E-Mail: ___________________________ Work E-Mail: _________________________________
Web Site: ___________________________________
                                PROFESSIONAL INFORMATION


Medical/Legal Practice Area (Select no more than 6)

___ AHC Administrative Health Care Law         ___ PIP Personal Injury, Plaintiff

___ CA Case Management                         ___ PIPD Personal Injury, Plaintiff/Defense

___ CM Criminal                                ___ PLD Product Liability, Defense

___ EL   Elder Law                             ___ PLP Product Liability, Plaintiff


___ LCP Life Care Planning                     ___ PLPD Product Liability, Plaintiff/Defense

___ MMD Medical Malpractice, Defense           ___ PHB Rehabilitation

___ MMP Medical Malpractice, Plaintiff         ___ RM   Risk Management

___ MMPD Medical Malpractice, Plain./Defense   ___ TT    Toxic Torts

___ PID Personal Injury, Defense               ___ WC Workers’ Compensation

___ Long-Term Care/Nursing Home




Settings (Select no more than 3):

___ Business & Industry                        ___ Consulting Firm

___ Government Agency                          ___ Health Management Organization

___ Hospital                                   ___ Independent Practice

___ Insurance Company                          ___ Law Firm

___ Other
                                  CLINICAL NURSING EXPERIENCE
Please use the following Key: (W=Expert Witness, E=Experienced, C=Clinically Active.) If only check marks
are present, they will be entered as "Experienced" on the website database.


___ ADM Administration/Office

___ AMB Ambulatory Care/Outpatient                       ___ NS    Nursing Standards

___ BDDD Birth Defects/Developmental Disabilities        ___ NT    Nutrition

___ BRN Burn                                             ___ OB     Obstetrics/Labor & Delivery

___ CHN Community Health                                 ___ OH     Occupational Health

___ COR Correctional                                     ___ ONC Oncology

___ CS   Clinical Specialist                             ___ OPT Ophthalmology

___ CV    Cardiovascular                                 ___ OR     Operating Room/Surgery

___ DB    Diabetes                                       ___ OT     Orthopedics

___ ED    Education                                      ___ PA     Physician Assistant

___ END Endoscopy/Enterostomy                            ___ PACU Post Anesthesia Care Unit

___ ENT Ear/Nose/Throat                                  ___ PAR Paramedic

___ ER   Emergency/Trauma                                ___ PAIN Pain/Stress Management

___ FLN Flight Nursing                                   ___ PED Pediatric

___ FOR Forensic Nurse/Sexual Assault                    ___ PHR Pharmacology

___ FS   Federal Medical Survey                          ___ PLS    Plastic Surgery

___ GEN Genetics                                         ___ PSY    Psychiatric/Mental Health/

___ GER Gerontology/Nursing Home                         ___      Chemical Dependency

___ GYN Gynecology                                       ___ PUB     Public Health/Epidemiology

___ HH   Home Health                                     ___ PUL     Pulmonary

___ ICU Intensive Care                                   ___ QA     Quality Assurance/Assessment
___ IC   Infection Control/Aids                         ___ RHB Rehabilitation

___ IV   Intravenous Therapy                            ___ RM      Risk Management

___ MS   Medical Surgical                               ___ SCI     Spinal Cord Injury

___ NA   Nurse Anesthetist                              ___ SN       School/Camp Nurse

___ NEP Nephrology                                      ___ TSPT Transplant

___ NEU Neurology/Head Injury                           ___ SN       School/Camp Nurse

___ NM Nurse Midwife                                    ___ SM       Sports Medicine

___ NN Neonatal/Newborn                                 ___ UR       Utilization Review

___ NP Nurse Practitioner                               ___ URO      Urology

___ NR   Nursing Research                               ___ OTH      Other_____________________




                                     COMMITTEE INTEREST

___ By-Laws           ___ Finance          ___Program/Education         ___Publication

___ Hospitality ___ Marketing/PR    ___ Nominating                ___ Membership




                                    LICENSURE INFORMATION

RN License Information: _______________ State: _______ Expiration Date: _____________

National AALNC Number: ____________ Expiration Date: _____________

**A copy of your National AALNC card MUST be on file with our Chapter.
                                   MEMBERSHIP CATEGORY

Note: Active and Associate members MUST be members of AALNC National organization.

Check One:     New Member__________                 Renewal___________

Type of Membership: (Check one)

___ Active

       ___One-year ($65)

                                    Active membership in the Association may be granted to any registered nurse
                                    who maintains active licensure in the United States, or is recognized by the
                                    International Council of Nurses as a professional nurse who currently provides
                                    consultation on healthcare issues within the legal arena. Active members may
                                    vote, hold office, serve on committees, and partake of all other benefits of
                                    membership as may be determined from time to time by the Board of Directors.

___ Sustaining
       ___One-year ($175)

                                    Sustaining membership may be granted to individuals, firms, or groups with an
                                    interest in the goals and activities of the Association. Sustaining members will
                                    have a website presence at www.AtlantaAALNC.org

The deadline for renewal is January 31, 2012.
There is a late fee of $10 for those renewing their membership after January 31, 2012.
If renewing by mail, please ensure your payment is postmarked by the deadline.



I certify that this application was reviewed by me, and that all entries and information are
true and complete to the best of my knowledge.


Signature:_________________________________________________ Date:_____________________

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:7
posted:12/27/2011
language:
pages:5