Membership Application
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| Name of Organization |
| Provider #: |
| Contact Person: |
| Title: |
| Address: |
| City: State: Zip: |
| Telephone: E-Mail: |
| Please indicate below your type of Providership: |
| _______ Hospitals and Clinics |
| _______ Community College |
| _______ Professional/Voluntary Organization |
| _______ Long Term Care |
| _______ College/Nursing School |
| _______ Private Provider |
| List of Associate Members |
| 1. |
| 2. |
Mail to: Kathy Nash § IANCE Treasurer § Health Education Center 802 Kenyon Road § Fort Dodge, IA 50501 |
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