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Agency Membership Renewal

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Event: Agency Membership Renewal $880.00
Agency Contact First Name: *
Agency Contact Last Name: *
Agency Contact Email:*
Agency Name:*
Agency Contact Credentials:*
Agency Contact Phone:* ext.
Agency Contact Title:*
Agency Contact Fax:*
Agency Contact Address:*
Agency Contact City:*
Agency Contact State/Province:*
Agency Contact Postal Code:*
Agency-Designated Individual Member
Benefits include a subscription to Nursing Research, voting rights in elections and at the WIN Assembly, and a reduced registration fee for WIN's annual research conference
Name & Credentials:
Title:
Mailing Address:
City/State/Zip:
Telephone:
Fax:
Email:
Research & Information Exchange (R&IE) Contact
Please check here if the information is the same as the Agency Contact:
Name & Credentials:
Title:
Mailing Address:
City/State/Zip:
Telephone:
Email:
Exhibit Booth Contact
Please check here if the information is the same as the Agency Contact:
Name & Credentials:
Title:
Mailing Address:
City/State/Zip:
Telephone:
Email:
Advertising Contact
Please check here if the information is the same as the Agency Contact:
Name & Credentials:
Title:
Mailing Address:
City/State/Zip:
Telephone:
Email:
Agency Information
Nurse Education programs offered
Associate Degree:
Bachelor's Degree:
Generic:
RNs Only:
Graduate Degree:
Master's:
Doctorate:
Type of health care agency
Hospital:
Nursing Home:
Community Health:
School of Nursing:
Other (please specify):




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