Membership Information Package

Membership / Membership Information Package

The Membership Information Package which includes more information on the following:

Please complete the form below to access the download. Thank you.

Name(Required)

First Last

Title(Required)

Hospital Name(Required)

Affiliated System

Phone Number(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What is your primary interest/reason for inquiring about Hospital Membership(s)?(Required)

Are there specific outcome measures you are interested in?

How did you learn about NPIC?(Required)

Internet Search

Colleague Referral

Prior relationship with NPIC

Professional Meeting

Other

If referred, by who?

Additional Comments

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