Print,
Complete, and Mail Application to:
Morristown NJ Chapter of
AALNC
470 Schooleys Mountain Road
Suite 8 ,
Box 186
Hackettstown, New Jersey 07840
Contact
Information
Last
Name:___________________________
First Name: ________________________ MI: _____
Business Name:________________________________________
Business Address:__________________________________
Business Phone:________________________
Business Fax:_________________________
Email:__________________________________________
Home Address: ____________________________________
Home City/State/Zip: __________________________________________
Home Phone: _________________________
Preferred Mailing: Home_________________
Business_______________
RN License #: ________________________ State
Issued:_______________
Exp Date:_______________
Practice: Independent _____________ In-House Law Firm
_____________
Other _____________
Highest Level of Education:
_________________________________________________________
Certification (Full Title):
____________________________________________________________
Type of Membership
Active: $50.00 _____________
Must be an RN who currently provides
consultation on healthcare issues within the legal arena.
Active members may vote,
hold office, serve on committees and partake of all other
benefits of membership.
An active member must be a member of the AALNC.
Please provide AALNC ID#: _________
Associate: $40.00____________
Must be an RN with an interest in legal issues.
Sustaining: $100.00___________
Membership granted to individuals or groups
with an interest in the goals and activities of the Association.
Method of Payment: Check
____________ Money Order ______________
Medical-Legal Practice Area
(select no more than six):
____ AHC Adm. Health Care
Law ____MMD Med Mal Defense
____ CA Case Management ____ MMP Med Mal
Plaintiff
____ CM Criminal ____ PID
Personal Injury Defense
____ EL Elder Law ____ PIP
Personal Injury Plaintiff
____ EXW Expert Witness ____ PIPD Plaintiff
and Defense
____ LCP Life Care Planning ____ PLD Product
Liability
Defense
____ Rehabilitation ____ PLP
Product Liability Plaintiff
____ RM Risk Management ____ Plaintiff and
Defense
____ IT Toxic Torts ____ WC
Worker’s Comp
Clinical Nursing
Experience/Area of Practice:
Please list your nursing
experience. If you are an expert witness in a particular area,
please indicate.
1.
__________________________________________
2. __________________________________________
3. __________________________________________
4. __________________________________________
5.
__________________________________________
Committee Interests (for
Active Members only):
____
Membership ____
Bylaws _____ Finance
____ Nominating ____ Publicity / Marketing
____ Publications ____ Education
Authorization &
Agreement/Verification
I authorize publication of
information contained within this application in the NJAALNC
Membership Directory.
________________________________________________
Signature Date
I certify that this application
was reviewed by me and that all entries and
information are true and complete to the best of my knowledge.
________________________________________________
Signature Date
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