Online Application – ICPSNE – Infection Control Professionals of Southern New England

Application Type*

New Member
Membership Renewal

DUES: $30 Yearly

Membership Type:*

Active (Individuals who are currently practicing or managing infection prevention or epidemiology programs.)
Associate (Individuals who are not actively involved in the practice or management of infection prevention or epidemiology.)
Retired (Individuals who are retired, but wish to maintain a connection to the ICPSNE organization.)

Name*

First Last

Professional Designations

Facility or Organization*

Job Title*

Preferred Contact Address*

Street Address Address Line 2 City State ZIP Code

Phone

Email*

Area of Focus

Long term Care
Utilization Management
Community Health
Infection Control
Nursing QA/QM
Hospital-wide QA/TQM/CQI
Risk Management

Area of Focus (Other)

Date*

Confidentiality Statement: My signature below indicates I understand any information obtained during ICPSNE meetings/activities (written, verbal, or other form) about other members, and/or their organizations of employment shall remain confidential.*

APIC Member*

Yes
No

CIC*

Yes
No

Coupon

Total (DUES: $30 Yearly)

$0.00

Credit Card*

Card Details

Cardholder Name

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Comments

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Member Application (New Member and Renewal)