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MAC/LPN Mailing List Application Form

MAC/LPN is not a formal membership organization; there are no membership dues. There is, however, a $25.00 contribution to cover the cost of mailings and the MAC/LPN Directory.

To receive program announcements and a copy of the Directory, complete the following form online; and send a $25.00 check made payable to MAC/LPN to:

    MAC/LPN
    c/o Susan Drew Thomas
    4004 Tenth Street NE
    Washington, DC 20017

 

First Name:

Last Name:

Organization:

Address:

City:

State:

Zip:

Work Phone:

Home Phone:

Fax Number:

E-mail Address:

Please print or type a description of your areas of interest/expertise for inclusion in the Directory. You may wish to include work setting, population, assessment tools, certifications/licenses, etc. Limited to 250 characters:

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