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MEMBER INFORMATION & INTEREST FORM

General Information:

Name:
Job Title & Specialty:
Home Address:
Home Phone: 
Home E-mail:

Employer:
Work Address:
Work Phone:
Work E-mail:

Members on the Move Information:

Award, Presentation, Publication, Research, Grant, etc.

Media News Story:

Briefly describe an interesting story on nursing excellence.

Committee Interest:  Check the Box(es) that you would like to be involved.

Program Publicity
Newsletter Chapter Leadership
Research Membership
Infomatics Fundraising

Special Chapter Projects:  Check the boxes that you would like more information on how to be involved.

Girl Scouts Obesity Prevention Project
Build with Habitat for Humanity

    

 

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Sigma Theta Tau Beta Mu · College of Nursing · 1305 N. Martin · Tucson, AZ  85721-0203

(520) 694 - 7577 · Email: President

Copyright ©2008 - 2009 Sigma Theta Tau, Beta Mu Chapter