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Association of Pediatric Gastroenterology and Nutrition Nurses Membership Application Form

You can fill this form out and send it online. You can also view or print it as an Adobe PDF and fax or mail it in. Need the free Acrobat Reader?

* indicates a required entry

*Name:
Title:
Place of Employment:
Employment Address:
City:	State: Zip:
*Home Address
City:	State: Zip:
Work Phone:	(include area code)
Home Phone:	(include area code)
*Email:
*Nursing Education:	Year Graduated:
Graduate Education:	Year Graduated:
*Highest Degree Held	Associate LPN BS	RN MS Other
Pediatric Nursing Experience:
Research Experience:
Membership in other GI Societies
Applying for:	Full Membership Reciprocal Membership
Please check if you are interested in participating in an APGNN subcommittee:	Program Membership Professional Development	Patient & Family Ed Newsletter Nominating
How did you learn about APGNN?

Please note: Recent CV or Resume must accompany application.
One reference or sponsoring letter is required with application. This letter should be from an APGNN Full Member or Gastroenterology/Nutrition Supervisor.
If you are sending online, you will be billed for your annual membership fee of $50, pro-rated to $25 for applications received after April 1 and before September 1. Email your accompanying documents to nabmoore@home.com

If you're mailing this form, enclose CV, reference letter and $50 (pro-rated to $25 if mailed after August 1) membership fee payable to "APGNN" to:

Nancy Moore, RN, MSN
APGNN Membership Committee Chairperson
Johns Hopkins Hospital
Brady 320
600 Wolfe St.
Baltimore, MD 21287

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