Last name:_______________________________ Full name:________________________________

Address: ___________________________________________________

Address: ___________________________________________________

City, State: ______________________________________________ Zip: _______________________

Phone: ______________________________________Fax: __________________________________

E-mail: _________________________________________ Membership Category: _______________

I=Individual; P=Program; A=Associate; S=Student

Are you the program director? Yes or No (Circle One)

Institution: ___________________________________________________________________

What is your position/title? ______________________________________________________

% time you spend in faculty position: ___________________

Highest level of education: _____________ 1=Baccalaureate; 2=Master's; 3=Doctorate; 4=Other

# Years in current position: _____________

# Years as NP: __________________ NP specialty: __________________________________

Does your nursing program own and/or operate a nurse-managed center (academic nursing

Do you practice clinically? Yes or No (Circle One)

Explanation of clinical practice: __________________ 1=part of paid teaching job; 2-separate paid job;

Approx. # of hours per week in clinical practice: __________________

Setting and type of practice: ____________________________________________________________

Are you involved in research activities: ___________________________________________________

Describe current project: _______________________________________________________________

Gender: _____________Age: ________1 = 25-29; 2= 30-39; 3= 40-49; 4 = 50-59; 5 = 60-65; 6 = 65+

Your race/ethnicity. Select one or more 1=Am. Indian/Alaska Native; 2= Asian 3=Black/African American;

Optional - Special Interest Groups ____________________

Mark in the box above to join or continue your participation in any of the current SIGs ($15 per SIG).

N=Academic Nursing Center A=Acute Care NP D=Distance Learning E=End of Life Care

G=Gerontological I=International Y=Program Director P=Psych/Mental Health NP R=Research

Additional Information:

1. If you do not wish to be listed in the membership directory, please check here_____.

2. Would you be willing to participate in a faculty needs assessment conducted by

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BALTIMORE, MD 21275-5072. CALL 202-289-8044 WITH QUESTIONS.