<p> THE CONNECTICUT CHAPTER OF THE AMERICAN ASSOCIATION OF NURSE ATTORNEYS, INC. MEMBERSHIP APPLICATION/RENEWAL AND MEMBERSHIP DIRECTORY INFORMATION </p><p>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.) </p><p>Please complete the information below. For renewals, complete information if changed from the information listed in the last membership directory.</p><p>Name ______Home Address: ______</p><p>Business Name:______</p><p>______</p><p>Business Address: ______Home Phone: ______</p><p>______E-Mail Address: ______</p><p>Business Phone: ______Fax Number: ______</p><p>Please check preferred mailing address: [ ] Home [ ] Business</p><p>Membership category: [ ] Voting: Nurse-attorney, nurse in law school or attorney in nursing school</p><p>[ ] Non-voting: Legal Nurse Consultant, Registered Nurse, Other interested person</p><p>Degrees, institutions and dates: ______</p><p>______</p><p>______</p><p>Description of your area(s) of practice: ______</p><p>______</p><p>______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</p>