ITNS Membership Application Form

[For printable version, download Membership Application (PDF) and mail in your check via U.S. Mail]

Note: Required Fields appear in RED

CONTACT INFORMATION
First Name:
Last Name:
Degree / Certification:
Recruited By:
I heard about ITNS through:	Colleague ITNS web site ISHLT ANNA ATC NATCO EDTNA Transplant Games BTS Contemporary Forums ITNS Educational Materials Other
Preferred Mailing Address:	Home Work
Preferred Email Address:
HOME ADDRESS
Street:
City:
State/Province:
Postal Code:		Country:
Phone Number:
WORK ADDRESS
Hospital/Company:
Position:
Department/Division:
Building/Room:
Street:
City:
State/Province:
Postal Code:		Country:
Phone Number:
Fax Number:
DEMOGRAPHIC INFORMATION
How many years have you been a nurse? less than 2 years 2-3 years 4-5 years 6-10 years 11-19 years more than 20 years
How many years have you been in Transplantation? less than 2 years 2-3 years 4-5 years 6-10 years 11-19 years more than 20 years
Work setting? University Affiliated Military Academic Community/Private Registry Government Organ Procurement Other
Area of Employment? Transplant Unit Clinical Research ICU Outpatient Pediatrics Other
Your Position? Staff Nurse Head/Assistant Head Nurse Supervisor In Service/Staff Development Clinical Nurse Specialist/Clinician Nurse Practitioner Charge/Team Leader Nursing Admin Transplant Coordinator Instructor Other
Which organ / tissue recipients do you care for? Liver Kidney Composite Bone Marrow Lung Heart Pancreas Islet Cell Small Bowel Other
Highest level of Nursing Education? Student LVN/LPN RN RN ADN RN BS RN BSN RN Diploma Masters Degree NP Doctorate RN BScN DNSc
Do you care for pediatric recipients? Yes No
I would be interested in receiving information for the ITNS Special Interest Groups (SIG) Education Research Cardiothoracic Staff Nurse Pediatric Advanced Practice Other SIG Interest
I am also a member of: AACN ANNA EDTNA ETCO ISHLT NATCO ONS BTS Sigma Theta Tau Other
CHAPTER AFFILIATIONS
Active Chapters:
International Chapters:
Developing Chapters:
TRANSPLANT-RELATED EDUCATIONAL ANNOUNCEMENTS
ITNS occasionally provides or sells its membership list strictly for the dissemination of transplant-related educational announcements. Please indicate if you would like your name to be included when our list is distributed to other organizations and transplant-related companies. Yes No The ITNS E-Update Newsletters are delivered to our worldwide membership on a bi-weekly basis. Please indicate if you would like to be subscribed to our FREE electronically delivered (via Constant Contact) newsletter. Yes No
MEMBERSHIP AGREEMENT
I have read and agree to abide by the ITNS By-Laws as written and amended. Download ITNS By-Laws (PDF)
IS YOUR PAYMENT IS BEING MADE BY SOMEONE ELSE? If the credit card is not the registrant's card, such as a hospital or corporate card, please provide the following information on the individual or organization making the payment.
Cardholder Name:

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