CVC Electronic Member Application

Central Virginia Chapter AALNC Electronic Member Application.

Please fill out this form and click "Register".
After registration, you will be directed to a PayPal page to pay the registration fee.

Name ■

Please enter your first and last name.

Your E-Mail Address ■

Credentials

(BSN, RN, LNCC, etc.)

How did you find out about our chapter?

If referred by someone, please let us know who

Preferred Mailing Address ■

(If your home address is preferred, a company WILL NOT appear in any directories published by CVC-AALNC.)

	Business	Home
Please select one.

Company

Company name

Address ■

City ■

State ■

ZIP/Postal code ■

Web site

If you or your company have a website, enter the URL here.

Home Phone

Business Phone

Cell Phone

Preferred Telephone ■

	Business	Home	Cell
Please select one.

Business/position

Please indicate what you do at your job or business.

RN License number

RN License state

RN License Expiration Date

/ / :

AALNC membership number ■

National membership in AALNC required for membership in local chapters.

Clinical Nursing Experience/Area of Practice ■

AALNC and Professional Activities

Medical/Legal Practice Setting(s)

Business/Industry

Consulting Firm

Government Agency

Health Management Organization

Hospital

Independent Practice

Insurance Company

Law Firm

Other Practice Setting

Please include me in the online member directory. (This is optional, and the directory is only available to other members.)

You must agree to the following to join:

I understand I must join National AALNC prior to joining the local central Virginia chapter.

I understand I must remain a member of AALNC in order to maintain CVC membership.

Signature ■

Membership is valid for one year upon payment. Dues are non-refundable and non-transferable. Payment of dues is not tax deductible as charitable contribution for income tax purposes but may be deducted as a business expense. Please consult your tax advisor.