AALNC - GREATER INDIANAPOLIS LOCAL CHAPTER MEMBERSHIP FORM

Transcription

1 Greater Indianapolis Chapter of AALNC American Association of Legal Nurse Consultants PO Box AALNC - GREATER INDIANAPOLIS LOCAL CHAPTER By-laws of the National AALNC require membership in the National organization before membership in the local chapter can be accepted. It is the Privacy Policy of the Greater Indianapolis Indiana Chapter of AALNC to release no information to parties outside of the Chapter except by express written permission of the member. Two Categories of Membership: Check the level you wish to join. 1.) Registered Nurse: $45.00 First year ** Must be an R.N. with a current license. Must be a member of National AALNC. $35.00 Renewal (*Renewal after May vote, hold office and serve on committees. March 1 st is $45.00) 2.) Non Registered Nurse: $35.00 First year ** Must be a member of National AALNC. $25.00 Renewal (*Renewal after March 1 st is $35.00) New members joining July 1-December 31 st $30.00 for both Registered Nurse and Non Registered Nurse membership. Please check the appropriate box above and include the appropriate funds. (Page One of Four)

2 AALNC - GREATER INDIANAPOLIS LOCAL CHAPTER Name: Dues for Year of: National AALNC Member #: Expiration Date: A copy of your active RN Registered Nurse License #: Expiration Date: license must be enclosed. Facility name of current employer: Employer address: Work Phone: Work Fax (W): Home Address: Home Phone: Home Fax (H): Areas of Clinical Practice: Years of Experience: Year graduated from Nursing School: Name of School: Year(s) completed of any LNC program: Name of School: Year graduation from Paralegal School: Name of School: Educational Background Check all that apply and list the area in which the degree is held: AD PhD BS Nurse Practitioner MS Physician s Assistant Paralegal Other Specialty Certifications Legal Nurse Consulting experience: No experience, interested in learning Independent Consultant list experience (years or number of cases) In a Law Firm: Full-time (years experience) Part-time (years experience) Hospital Risk Management/legal department (years experience) Insurance Company (years experience) (Page Two of Four)

3 AALNC - GREATER INDIANAPOLIS LOCAL CHAPTER Make Check out to: Mail to: P.O. Box 1702 Indianapolis, Indiana ***** If you mail in please also send an to info@indyaalnc.org so the treasurer;/secretary is aware mail is pending, thank you ***** Dues are nonrefundable. Dues to AALNC Greater Indianapolis Chapter cannot be deducted as charitable contributions, but may be deductible for federal income tax purposes as ordinary and necessary business expenses. Consult your tax advisor for individual assistance in specific situations. Declaration: I, hereby declare that all information herein is true and to the best of my knowledge. Date: Signature: (Page Three of Four)

4 Greater Indianapolis Chapter of AALNC American Association of Legal Nurse Consultants PO Box MEMBERSHIP DUES INVOICE YEAR 2014 Benefits of membership: A minimum of six (6) educational meetings a year. No meetings the month of National conference, June, July, August and December. Educational meetings are free to members. Local chapter electronic minutes Electronic postings of possible job openings Networking opportunities with local and national members for professional growth All business meetings held on the 3 rd Wednesday of the month at 5:30pm, except as listed above. Please check the website and s for details of the location as this may change. For further information contact: Make Check out to / Mail to: Linda Slack, R.N. LASSLACK@aol.com P.O. Box 1702 ** also send to info@indyaalnc.org to alert the secretary/treasurer mail is present at the PO Box**... Please detach and return with your payment Name: Remit by February 28, 2014 Please Circle Your Choice: Registered Nurse - First Time Member $45.00 Registered Nurse - Renewal $35.00 Registered Nurse - After March 1, 2014 $45.00 Registered Nurse - First Time Member after July 1, 2014 $30.00 Non-Registered Nurse - First Time Member $35.00 Non-Registered Nurse - Renewal $25.00 Non-Registered Nurse - After March 1, 2014 $35.00 Non-Registered Nurse - First Time Member after July 1, 2014 $30.00 (Page Four of Four) revised to reflect the updated National Bylaws, Chapter Bylaws pending. INDS02 PSF April 8, 2014

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