Membership Application

These forms are for new applicants. Existing KCNPNM members new to this website click here register for website access.)
Apply via mail
You can apply for membership via mail by printing out one of the following forms and returning it to KCNPNM.

Application in MS Word Format
You must have Microsoft Word, or a compatable reader to view/print this document.

Application in PDF Format
You must have Adobe Reader, or a compatable reader to view/print this document.

Online Membership Application

Please complete the form below. This information will be used to verify your application and update our database. We do NOT sell, trade, or otherwise transfer information such as email addresses to third parties except as you permit below.

Please Ensure Accuracy! Our mailing list and annual directory are created from the information you provide here.

Fields in RED are required.

Membership Status:
Which should I choose?

First Name:

Middle Initial:

Last Name:

Credentials:

Preferred Mailing Address:

Preferred Mailing Address Line 2:

City:

County: Example: Fayette for Lexington, Jefferson for Louisville. PLEASE NOTE! This is not COUNTRY.

State:

Zip:

Home Phone: - -

Work Phone: - - ext:

Fax:

Email Address:

Practice Name: (For ARNPs only)

Practice Address:

Practice City:

Practice State

Practice Zip:

Specialty:

Practice County 1:

Practice County 2:

Practice County 3:

Choose a username to access this website. Usernames and passwords must be at least 6 characters long, have NO SPACES and contain only letters and/or numbers. No special characters like question marks, commas, pound symbols(#), etc...

Username:

Password:

You may release my name and address for Non-KCNPNM mailings

Include me in KCNPNM's directory published each July

Copyright© 2004, Kentucky Coalition of Nurse Practitioners/Nurse Midwives
All Rights Reserved

Kentucky Coalition of Nurse Practitioners/Nurse Midwives
For contact information, click on CONTACT US at upper left.