ACNM Region IV, Chapter 7 (Southeastern Michigan)
APPLICATION FOR MEMBERSHIP
2008-2009

Name (First, Middle Initial, Last)_______________________________________________________________________

Address____________________________________________________________________________________________

    City_______________________________________State_____________________Zip Code_________________

Home Phone  (                     )____________________________________________________________________________

E-Mail Address______________________________________________________________________________________

Employer___________________________________________________________________________________________

        Hospital / physician / other health organization / self  (circle one)

Job Title_________________________________________________   Years as a CNM____________________________

Work Address_______________________________________________________________________________________

              City________________________________________State___________________Zip Code__________________               

Work Phone  (                 )______________________________________________________________________________

Pager Number  (               )_____________________________________Voice / Digital (circle one)

Fax Number  (               )_______________________________________Home / Work (circle one)

 

Membership is:  [  ] New            [  ] Renewal

Dues:  [  ] Active Member - $40      [  ] First Year Eligible - $30      [  ] Student - $20

          [  ] Friend of nurse-midwifery (non CNM/SNM) – donation  $______________________________

 
Please make check (for the correct amount) payable to: ACNM Region IV, Chapter 7.

Please mail this application and check to: Laurie Bania, CNM, 5051 Whipple Lake Road, Clarkston, MI 48348



Please answer the following question:

Are you willing to have your name, address, phone number, and e-mail address included on the chapter membership list for
distribution to the chapter members for personal networking only?      [  ] Yes      [  ] No

PLEASE TURN OVER TO COMPLETE MEMBERSHIP SURVEY ON THE REVERSE SIDE.


ACNM Region IV, Chapter 7 (Southeastern Michigan)

  MEMBERSHIP SURVEY

 

What kind of midwifery care do you provide in your current employment?  (Check all that apply) 

      [  ]  Antepartum  [  ]  Labor/Birth  [  ]  Postpartum  [  ]  Well Woman  [  ]  Newborn Care  [  ]  Other________________

 
Are you interested in serving on a Chapter committee?  [  ] Yes            [  ] No            [  ] Maybe later

    Which committee(s)?  (Check as many as you wish)

                                [  ] Education

                                [  ] Nominating
 
                                [  ] Student Affairs

                                [  ] Political and Economic Affairs (PEAC)

                                [  ] Publicity and Public Relations

                                [  ] Membership

 Would you be interested in serving on an ad hoc Chapter committee for accomplishment of special tasks?

     [  ] Yes            [  ] No            [  ] Maybe later

 
Are you interested in serving as a Chapter officer?  [  ] Yes            [  ] No            [  ] Maybe later

      Which officer?  (Check as many as you wish)

                                [  ] Chapter Chair

                                [  ] Vice Chair

                                [  ] Secretary

                                [  ] Treasurer

 

  In addition to CNM, do you hold any other certifications?  [  ] Yes            [  ] No

    What other certifications (i.e. FNP, PNP, ANP, CRNA, ICBLC, etc.)?  _______________________________________

 
If student, where at?  __________________________________________________________________________________
      Expected graduation date____________________________________________________________________________

 

Comments and/or questions?