Nurse Practitioner and Physician Assistants Section Membership Form

Your Information

First Name

Last Name

Designation(s)

Gender

MaleFemale

Institution or Practice Name

City

State

Country

Email Address

Training, Education and Affiliations

I am a:

Nurse PractitionerPhysician AssistantOther

Other

Completion (Year)

NP Program Name

PA Program Name

Completion (Year)

Affiliations with other professional organizations:

AANPAAPA

List your involvement in either the AANP or AAPA and any other related organizations (including Angio Clubs, chapters etc). Also include past or current involvement in any local institution/practice committee that may be pertinent to this section's activities.

	Organization/Group	Role (member, committee member or position)

Section Membership

Section membership will be comprised of SIR Clinical Associate members who are Advanced Practice Nurses (ie Nurse Practitioners and Clinical Nurse Specialists) or Physician Assistants who have a special interest in contributing toward the objectives of the section. Activities of the section are targeted to NPs and PAs; however, membership is open to all SIR members interested in supporting the mission of this section.

Membership in the NP and PA Section requires that you are a SIR Member in good standing. To verify your SIR membership, visit: https://sir.personifycloud.com/personifyebusiness/MyAccount.aspx

I am a SIR member in good standing

List and describe your interests pertaining to this section (education, mentorship, awareness/recruitment, research etc):

List any project ideas for the NP and PA Section. Also include any contributions or experience that you can offer to the NP and PA Section:

Clinical Information

Your Current Practice Type

Collaborate

Collaborating with your professional network can be beneficial to this section's activities. List any colleagues who may be interested in learning more about or joining this section.

Name of Colleague

Role (physician, NP, PA)

Membership?

SIR MemberNon MemberI don't know

Email address, if known

Thank you for completing the NP and PA Section Membership form. Please click the SUBMIT button below.