ICN 2023 Membership renewal form

Organization Name*

Address*

Street Address Address Line 2 City State ZIP Code

Do you have a PO #*

Yes
No

2023 Membership Fee Calculation

Membership Type*

Schools of Nursing
Healthcare Provider and other Organizations

Schools of Nursing Membership

From the choices below, please carefully choose your desired MEMBERSHIP TIER and TOTAL NUMBER OF STUDENTS, INCLUDING DISTANCE LEARNERS, at your school.

2023 ICN Membership Fees for Schools of Nursing

2023 Membership Fees

$0.00

Healthcare Provider and other Organizations Membership

From the choices below, please carefully choose your MEMBERSHIP TIER and total number of RN FTEs for your organization.

2023 ICN Membership Fees for Healthcare Providers and Other Organizations

2023 Membership Fees

$0.00

Board of Directors Representative

Name*

First Last Credentials

Title*

Email*

Enter Email Confirm Email

Phone*

Would you like your administrative assistant copied on the invoice?*

yes
no

Administrative Assistant Name

First Last

Administrative Assistant Email

Enter Email Confirm Email

Do you want an invoice sent directly to your organization's accounts payable/finance department?*

yes
no

Accounts Payable/Finance Dept. Representative Name

First Last

Accounts Payable/Finance Dept Email

Enter Email Confirm Email

e-signature*

This electronic signature attests to the accuracy of the information above

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2023 Membership Fee Calculation

Schools of Nursing Membership

Healthcare Provider and other Organizations Membership

Board of Directors Representative

INDIANA CENTER FOR NURSING

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