INPS Membership Application 

Name___________________________________________________________

 Address_________________________________________________________

 City________________________________State_____________ZIP________

 Phone with area code:

 Home___________________Work_____________________FAX__________

 Email (for INPS use only)___________________________________________

 Specialty_________________________________________________________

 Graduation Date if Student___________________________________________

 Annual Dues (check one)

Regular Membership -$80 _____                 Student Membership -$20_____

2 Year Membership  -$150 _____

 

Associate Membership -$40 _____              Joint IANP -$40 _____

                                                                        (enclose copy IANP card)

 

Check One

 

New_____                   Renewal_____                       

Mail Form to:

Dixies Harms
2800 NW 152nd Street
Clive, IA 50325