Nurse Practitioner Association of South Dakota

Date	September 6th, 2010
Title
* First Name
* Last Name
* Home Address
* City
* Region	What side of the river are you located? West Middle East
* State
* Zip
Home Phone: Use this format please XXX-XXX-XXXX
Home Email:

* Name of place that you work at

* Work Address
Second Line Address
* City
* State
* Zip
Work Phone: Use this format please XXX-XXX-XXXX
Work Email:
Work Webaddress:

List all states of licensure

Area of Nurse Practitioner Certification


Certifying Body	ANCC AANP Other

Area of Expertise


* Membership Status	Regular Student


Regular membership is limited to certified or licensed Nurse Practitioners. Applicants meeting the stated criteria will not be discriminated against on the basis of race, color, religion, sex, disabilities, or national origin. Your voluntary contribution will assist in the development of your professional organization. Please be aware dues are not tax deductible. Send Check or Money Order To: NPASD PO Box 2822 Rapid City, SD 57709

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