AALNC GREATER CHICAGO CHAPTER

MEMBERSHIP APPLICATION

Name: ______________________________________________________________ Date: ____________________

Address: ______________________________________________________________________________________

City: _______________________________________   State: ________________   Zip: ______________________

Work: (       ) _____________________________              Home: (        ) _________________________________

Fax: (       ) ____________________        E-mail: _______________________________(mandatory for announcements)

Primary Employer: _____________________________________ Position/Title: _____________________________

Secondary Employer: _____________________________________________________________

Preferred Mailing Address:

_______________________________________________________

_______________________________________________________

Preferred Phone: __________________________

Renewal: _________    New Member: ____________

I am joining/renewing as a:

____ ACTIVE MEMBER: (current RN license, member of AALNC national organization, and practice as a Legal Nurse Consultant (LNC) within the last 12 months) $50.00 (October through October).  $25.00 for members joining after April 1st of the current year.

____ ASSOCIATE MEMBER: (Current RN license, member of AALNC national organization, but have NOT practiced as a Legal Nurse Consultant within the last 12 months) $50.00

____ SUSTAINING MEMBER: (NOT a registered nurse but interested in promoting the goals and principles of AALNC, Sustaining membership in the national AALNC) $75.00.

CLINICAL NURSING EXPERIENCE:

Certification/Advance Degrees: ______________________________________________________

I am willing to testify as a nurse expert: ____ Yes ____ No

If yes, what type of cases (e.g. med/surg; OB, etc) _________________________________

Years of clinical experience in legal nurse consulting: _____________________________

Currently consulting as: __ in-house employee  __ independent LNC   __ expert witness  __ exploring options

AREAS OF LNC EXPERIENCE (check all that apply): _____ medical malpractice   ____ product liability

____ risk management   ____ personal injury  ____ worker's comp ____   forensic nursing

____ compliance   ____ medical fraud/abuse ____   life care planning Other: ___________

CHECK COMMITTEES INTERESTED IN JOINING (you will be assigned to a committee if none are checked)

___ Membership ____ PR/Marketing ____ Education ____ Publication  ___ Finance ____ Ethics

____ Nominations ____ By-laws   ___ Short term task force activities

*ALL NAMES ARE INCLUDED IN THE CHAPTER MEMBERSHIP DIRECTORY UNLESS REQUESTED OTHERWISE

I ____ do, ____ do not give my permission for the Greater Chicago Chapter to give out my name, address, and any information included on this application to parties who are not members (e.g., mailing lists, attorneys asking for referrals, etc.)

Signed: ___________________________________________

I understand that I must be a member of AALNC National in order to remain a member in good standing of the Chicago Chapter and that my chapter membership can be revoked without refund if I do not become a national member within the next sixty (60) days.

Signed: ___________________________________________

AALNC National Number(required): ____________________________

I am currently licensed RN in Illinois or one of its bordering states:

Signed: ___________________________  RN License #_______________________ (required)

PLEASE RETURN THIS APPLICATION AND ENCLOSED CHECK IN THE APPROPRATE AMOUNT MADE PAYABLE TO:

"AALNC Greater Chicago Chapter".

Please mail to:

Ms. Pat Thurman

16200 Woodbridge Ave

Harvey, IL   60426