AMERICAN ASSOCIATION OF LEGAL NURSE CONSULTANTS
SOUTH FLORIDA CHAPTER
PO BOX 400, FORT LAUDERDALE, FLORIDA 33302

NEW MEMBERSHIP & RENEWAL APPLICATION
YOU CAN COMPLETE THIS FORM AND SUBMIT IT ON-LINE

Select Membership Type:     Make Selection New Member Renewal
NAME:       
EMPLOYER/BUSINESS:       
MAILING ADDRESS:       
CITY:           STATE:           ZIP:       

TELEPHONE: (W):   (H):
FAX:                (W):   (H):
EMAIL:           (W):  

                      (H): 
CELL PHONE:(W):   (H):

BIRTH MONTH:        DATE:       
AREAS OF EXPERTISE:           Make Selection Yes No
SERVE AS AN EXPERT:           Make Selection Yes No
IF SO, WHAT AREAS
INDEPENDENT:           Make Selection Yes No
FIRM:           Make Selection Yes No
WILLING TO WORK PER DIEM OR ON A CASE BY CASE BASIS:    Make Selection Yes No
WILLING TO BE INVOLVED IN A SPEAKER'S BUREAU:   Make Selection Yes No  
IF SO, WHAT TOPICS:       
WILLING TO ALLOW ABOVE PERSONAL DATA TO BE MADE AVAILABLE ON CHAPTERS
WEBSITE FOR BUSINESS PURPOSES:     Make Selection Yes No   

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AALNC NATIONAL  MEMBERSHIP #:  
AALNC NATIONAL MEMBERSHIP EXP DATE:
Chapter membership expiration date is always December 31st of each year. You need to complete an application/renewal form each year.
CURRENT STATE OF LICENSURE:
ACTIVE LICENSE:   EXP DATE:

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ACTIVE MEMBER FEE:    $60.00/Year January 1 to December 31 per calendar year
                                                 $30.00/Year July to December 31 per calendar year

Method of payment is required before submitting the application.

Method of Payment: Please insert one of the following Payment Methods:
                   (PayPal, Check or Money Order)
           

*(Application, checks and National AALNC Card can either be mailed to the Chapter's address or completed on-line utilizing our Pay On Line services.)

Please consider being an ACTIVE member of the Chapter. Please indicate which of the following Committees are of interest to you. The Chairperson  for Membership will forward a copy of this application to the appropriate Chairperson, who will contact you directly and advise you of upcoming meeting information.

*A. Education                        
*B. Membership                      

Date:          
Applicant Signature:       

Date: _____________________   

Treasurer: _____________________________________

Once you have clicked Submit you will receive a response that your application has been sent. Click "Return to Form" at the bottom of the page which will take you back to this page. Then, click click here to access the "Pay Online" page in order to pay for your membership online.

*All fields above need to be completed prior to submitting the form unless noted with red asterisk(*).