Please print and fill out all the information below so that Chapter records as well

as your web page data will be correct. Home addresses and other personal 

information will not be included on the website.
Mail to:                                      Dues: CNM $110, SNM $37

Debby Popkin                                     Retired (after at least 10 yrs. active Chapter membership) $73

CT ACNM

930 Mount Vernon Road           Make checks payable to: ACNM Region 1 Chapter 2

Southington, CT  06489             Payments after January 1st, add $25 late fee

Name _________________________________________________

Home Address __________________________________________

______________________________________________________

City_________________________________Zip _______________     Please print!

Home Phone/Fax_________________________________________

Personal E-mail __________________________________________

How long have you been a Chapter member?  ________

Website Data:

Practice name: _________________________________________________________

ANY changes in your practice info since last year?       YES         NO     

Names of CNMs in practice:   **All CNMs in a group must be current in their dues for the practice to be listed on the website**

__________________________________   ___________________________________

__________________________________   ___________________________________
__________________________________   ___________________________________

County:____________________________

Types of service provided (please circle)        AP                IP                GYN

If applicable, where do you attend births?   

________________________   _______________________    _________________________

PLEASE ATTACH YOUR BUSINESS CARD, if applicable.

1.Office Address :_____________________________________

   _________________________________________________

 City:______________________ Zip __________

 Phone_________________  Fax __________________

2.Office Address :_____________________________________

___________________________________________________

City:______________________ Zip __________

Phone_________________  Fax __________________

3.Office Address :_____________________________________

___________________________________________________

City:______________________ Zip __________

Phone_________________  Fax __________________

4.Office Address :_____________________________________

___________________________________________________

City:______________________ Zip __________

Phone_________________  Fax __________________

5.Office Address :_____________________________________

___________________________________________________

City:______________________ Zip __________

Phone_________________  Fax __________________

I