ASPMN Chapter Intention Form

ASPMN Chapter Intention Form
Date

MonthDayYear
Date
Proposed Name of Chapter:*
- We are submitting our intentions to form a local chapter of the American Society for Pain Management Nursing® (ASPMN®).
- We understand a liaison will be assigned to our group, from the Chapter Support Committee, to help facilitate the process of becoming a chapter.
- We understand we will have a year to organize and submit the Petition to Charter form.
- We further understand that until the Chapter Charter is approved, we will not be granted chapter rights, however, the group is encouraged to meet prior to the charter being approved.
The designated contact person for our group is:
Name:*

First NameLast Name
Address:*
Preferred Phone Number:*
Preferred Email Address:*
The active members of our group are (a minimum of 5 members of ASPMN®)

Please provide the name, address, preferred phone number, and preferred email address for each member of your group.
Member One Information:
Member Two Information:
Member Three Information:
Member Four Information:
Member Five Information:
Do you have more than five members?*

YesNo
Please list all others of members of your group (Name, Address, Preferred Phone, and Preferred Email for each extra person:
Date

MonthDayYear
Date
Signature of contact Person:
Printed name of contact person:*
Should be Empty: