INPS Membership Application 

Name___________________________________________________________

 Address_________________________________________________________

 City________________________________State_____________ZIP________

 Telephone numbers:

 Home___________________Work_____________________FAX__________

 Email (for INPS use only)___________________________________________

FNP      ANP/GNP    PNP    ACNP    Other_____________

 Specialty_________________________________________________________

 Graduation Date if Student___________________________________________

 Annual Dues (check one)

Regular Membership    -$100 _____               Student Membership -$25_____

2 Year Membership       -$180 _____

Associate Membership  -$50 _____              Joint IANP -$50 _________

                                                                                     (enclose copy IANP card) 

Check One

New_____                   Renewal_____                       

Mail Form to:

Dixies Harms
2800 NW 152nd Street
Clive, IA 50325