AALNC Dallas, Texas Chapter
New Member/Renewal Application

The AALNC Dallas Chapter invites you to join or renew your local Chapter membership. The annual dues for active and associate members are $45.00. You must provide proof of membership in the National Association to be eligible for local chapter membership. Sustaining membership is $225.00 annually and does not require membership in the National Association. Membership is valid for one calendar year (January 1st through December 31st). Dues are non-refundable and non-transferable.

A Paypal transaction fee will be added to your membership when you apply online.

You may submit your completed application online (follow directions below for online payment using Paypal) or you may print and mail the printable version of this form with a check to:

ATTN: AALNC Dallas Chapter; Membership
PO Box 224376
Dallas, TX 75222-4376

Member Information

* denotes a required field
Date*:
Please Check*: Renewal          New Member
AALNC National Membership No*:
First name*:
Last Name*:
Credentials*
(e.g. BSN, RN, LNCC):
Employer/Business Name*:
Business Address*:
Business Telephone*:

Business Fax:

Home Address:

Home Telephone:
E-Mail*:
Preferred Mailing Address* (check one): Business       Home
RN License No*:

Membership Category
ACTIVE: Registered Nurse maintaining and active license who is working in a consulting capacity in a legal field.
ASSOCIATE: Registered Nurse maintaining an active license who is interested in the goals and activities of AALNC, but has NOT worked in a consulting capacity in the last 12 months.
SUSTAINING: An individual who practices law; or any other individual, business, organization or facility with an interest in the goals and activities of AALNC.

 

Professional Information
Medical/Legal Practice Area
(select no more than 6)		 Medical/Legal Practice Setting
(select no more than 3)

 


Other (describe):

Clinical Nursing Experience/Area of Practice
(select no more than 5)		 Expert Witness Areas of Expertise
Administration/Office
Ambulatory Care/Outpatient
Birth Defects/Developmental Disabilities/Genetics
Cardiovascular/Pulmonary
Clinical Specialist
Community Health
Correctional
Diabetes/Nutrition
Ear Nose & Throat/Ophthalmology
Education
Emergency/Trauma
Endoscopy/Enterostomy
Federal Medical Survey
Flight Nursing/Paramedic
Forensic Nursing/Sexual Assault
Gerontology/Nursing Home
Gynecology
Home Health
Infection Control/AIDS/Public Health/Epidemiology
Intensive Care
Intravenous Therapy
Medical Surgical/General Nursing Practice/Transplant
Neonatal/Newborn
Neurology/Head Injury
Nurse Anesthetist
Nurse Midwife
Nurse Practitioner
Nursing Research
Nursing Standards
Obstetrics/Labor & Delivery
Occupational Health
Oncology
Operating Room/Surgery
Orthopedics/Sports Medicine
Pain/Stress Management
Pediatric
Pharmacology
Physician Assistant
Plastic Surgery/Burn
Post Anesthesia Care Unit/Recovery Room
Psychiatric/Mental Health/Chemical Dependency
Quality Assurance/Assessment
Rehabilitation
Risk Management
School/Camp Nursing
Spinal Cord Injury
Urology/Nephrology
Utilization Review/Discharge Planning

Communications

Occasionally, the Dallas AALNC Chapter provides and/or sells its membership list to other chapters, agencies, and companies whose products or services may be of interest to legal nurse consultants. Please indicate below if you do not wish to have your name sold or provided as part of the Dallas Chapter's mailing list and/or directory. Upon approval of membership, member information will be placed in the membership directory on the Dallas AALNC Chapter website and the e-mail address added to the Chapter Listserv.
I do not want my name sold or provided as part of the Dallas Chapter AALNC mailing list.
I do not wish for my name and contact information to be placed in the membership directory and/or on the Dallas Chapter AALNC website.
Yes, I will accept broadcast e-mail and/or Chapter Listserv and telephone communications.
In submitting this application, I attest that the information provided is true to the best of my knowledge.