The Connecticut Chapter Of

THE CONNECTICUT CHAPTER OF THE AMERICAN ASSOCIATION OF NURSE ATTORNEYS, INC. MEMBERSHIP APPLICATION/RENEWAL AND MEMBERSHIP DIRECTORY INFORMATION

Membership dues are $35.00 per year. (No portion of such dues is allocable to nondeductible lobbying activities as The Connecticut Chapter does not engage in lobbying/political activities.)

Please complete the information below. For renewals, complete information if changed from the information listed in the last membership directory.

Name ______Home Address: ______

Business Name:______

______

Business Address: ______Home Phone: ______

______E-Mail Address: ______

Business Phone: ______Fax Number: ______

Please check preferred mailing address: [ ] Home [ ] Business

Membership category: [ ] Voting: Nurse-attorney, nurse in law school or attorney in nursing school

[ ] Non-voting: Legal Nurse Consultant, Registered Nurse, Other interested person

Degrees, institutions and dates: ______

______

Description of your area(s) of practice: ______

______

______Please send this form and a check payable to CT TAANA for $35.00 to: Gayle Sullivan, Esq., Treasurer The Connecticut Chapter of the American Association of Nurse Attorneys, Inc. c/o Sinoway, McEnery, Messey & Sullivan, PC Sturbridge Commons 250 State Street 1-E North Haven, CT 06473