INTERNATIONAL NURSES ANONYMOUS MEMBERSHIP APPLICATION
(Please duplicate and circulate)

PLEASE PRINT OR TYPE THE INFORMATION REQUESTED

Name:___________________________________________________________________

Mailing Address:_____________________________________________________

City, State and Zip Code:____________________________________________

Phone numbers: Home: (____)________________ Work: (____)______________

Location in State (North, East, South, etc...) __________________________

Date of Birth:___________________________ Sex: ______________

Basic Nursing Education: LPN_____ ADN_____ Diploma ______ BSN ______

Advanced Degree: MSN______ MA,MS/Other Discip _____ Doctorate ______

Twelve step program affiliation: AA_____ NA_____ OA_____ GA______
                                                Alanon_____ ACOA_____ Other (specify)_______________________

How did you find out about INA?__________________________________________________ ____________________________________________________________________________

DO YOU WANT YOUR NAME ON THE LIST THAT WILL BE PRINTED AND CIRCULATED TO MEMBERS? YES______ NO______ UNLESS THIS IS CHECKED YOUR NAME WILL NOT APPEAR ON THE MEMBERSHIP LIST. BE CERTAIN TO SIGN IN THE DESIGNATED PLACE BELOW)

May we call you to help another nurse in your area? Yes _____ No _____

Can you speak freely at work? Yes_____ No _____ Can you speak freely at home? Yes _____ No

E-Mail Address:____________________________________________________________

Permission to print e-mail address in newsletter: Yes _____ No _____

Signature ____________________________________________ Date: ____________

Please send to: Kathy Kavanaugh
Telephone: (704) 992-0678 Messages left to return long distance will be answered collect
14542 Greenpoint Lane, Huntersville, NC 28078

NO DUES OR FEES REQUIRED (DONATIONS GREATLY APPRECIATED)