A new tool for Advanced Practice Registered Nurses to

							APRN Assist:: A tool for Advanced Practice Registered Nurses
to find physicians willing to form collaborative agreements.

Name ________________________________________________________________

Address_______________________________________________________________

City___________________________________State_________ Zip______________

Phone________________________________Cell Phone______________________

E-mail ___________________________________________________________

Specialty focus of practice _________________________________________________

Towns/Cities wishing to practice in___________________________________________

Part-time_______________________ Full-time________________________

EDUCATION:
College::_______________________________________________________________

Advanced Degree:
______________________________________________________________________

Approved Nurse Practitioner Program _______________________________________

Other Degrees:__________________________________________________________

______________________________________________________________________

Years of Practice_____________________Years of Practice in
Connecticut_____________




   Please Return to: APRN Assist c/o CSMS, 160 St Ronan St., New Haven, CT 06511
                            or by FAX to (203) 492-3836
Previous employment
______________________________________________________________________________




   Please Return to: APRN Assist c/o CSMS, 160 St Ronan St., New Haven, CT 06511
                            or by FAX to (203) 492-3836