NORTHWEST INLAND EMPIRE CHAPTER
INTRAVENOUS NURSES SOCIETY
Membership Application 2010
Name:_______________________________________________________________
Address:______________________________________________________________
City:_________________________State:____________________Zip:_____________
Telephone:____________________E-Mail:___________________________________
____________Nurse __________Pharmacist __________Vendor
Employer:_____________________________________________________
Address:_______________________________________________________
City:__________________________State:________________Zip:_________
Telephone:___________________________E-mail:_____________________
Position:_______________________________________
CRNI ________Yes _______No _______Interested in becoming
National INS Membership #:_______________________________________________
Signature:________________________________________Date:__________________
DUES: $15.00 per year due by the 1st of March each year. Make checks payable to:
NW INLAND EMPIRE CHAPTER INS
MAIL TO: Mary Rosman
5818 N Haye
Newman Lake, WA 99025
Mary.Rosman@providence.org