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NCEMNA Member Enrollment Friday, September 03, 2010


Registration

Prefix:  
*First Name:  
Middle Initial:  
*Last Name:  
Suffix:  
Job Title:  
Organization Name:  
*Address Line 1:  
Address Line 2:  
*City:  
*State (US/Canada):  
Province:  
*Postal code:  
*Country:  
*Work Phone:  
Work Phone Extension:  
Home Phone:  
Other Phone:  
Other Phone Extension:  
Fax:  
* Email:  
*Login Name:
*Change Password:
*Confirm Password:
Age:
*Actively Involved in Research? Yes     No
*Are you currently, or have you been
a PI on any of your research projects? 		Yes     No
*Research resulted in peer reviewed
publications? 		Yes     No
*Willing to mentor others? Yes     No
If yes, Research Area:
*Interested in Doing Research?
(If not Involved in Research) 		Yes     Maybe     No
Barriers for not being involved in research:
*Interested in having a mentor? Yes     No
If yes, Research Area Assistance needed:


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*Highest Degree:
 *Nursing Credentials:

Other, specify:
*Race/Ethnicity:

Other, specify:
 *Employment Setting:
*Type of Job:
 *Membership:
*Current Research Areas:

Other, specify:
 Research is Currently Funded by:

Other, specify:
*Type of Support and/or training
needed to do research:

Other, specify: