Colorado Transplant Nurses Society Local Chapter of International Transplant Nurses Society Volume 7, Number 2 June 1, 2007

Colorado Transplant Nurses Society Local Chapter of International Transplant Nurses Society Membership Form (AND RENEWAL) Name:________________________________Credentials____________ Position/Title_______________________________________________ Home Address:___________________________________________________ City:________________________________ State:____________________ Zip:________ Work Address:___________________________________________________ City:________________________________ State:____________________ Zip:________ At which address do you prefer to receive CTNS correspondence? Home_______ Work________

Home Phone:___________________WorkPhone:____________________ Home Fax:_____________________Work Fax:_____________________ Home E-mail:___________________Work E-Mail:_________________ $10 membership fee – Send with completed application Please make check payable to: Colorado Transplant Nurses Society Mail to: ATTN: Kathy Orban Eller, RN, MS Kaiser Permanente Dept 6891 2550 S. Parker Road, Suite 300 Aurora, CO 80014

ITNS membership number __________________ Exp. ________________ (Remember, ITNS membership is required for local chapter membership For Office use: ITNS membership verified______________________________ Date Local membership paid ___________________________ 4