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MEMBERSHIP APPLICATION
University of Illinois Nursing and Healthcare Associates (UINHA)

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First Name*:
Last Name*:
Degree:
CON Department:
Percent Appointment:
(CON Only)
Work Phone*:
Email*:
Verify Email*:
Office #:
   
Interests and expertise (check all that apply)
I am interested in exploring the possibilities of working through the NSP to provide the following services:
  
Direct Patient Care
Consultation
Continuing Education
Specialty Areas:
Availability:
(Hours per Week)
Special Interests:
Comments: