Clinical Expert Panel Application Form

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NAPNAP Clinical Expert Panel Application

(Must be postmarked by May 15 or November 15)
Name:
Title:
Credentials:
Practice:
Address:
City:
State:
Zip:
Home Phone:   
Work/Message Phone:   
Fax:   
E-mail Address:   

Education: (include nurse practitioner education and highest degree held) NP
Education (Institution, degree/year):

Additional Education (Institution, degree/year):


Certification:




     
NAPNAP Member Number:  

Area of Expertise: In the area below, please indicate up to 3 (MAXIMUM) areas of expertise. Due to space constrains we will only be able to list up to 3 areas for each expert.





















age:












    
    type of diet:
    
    
    
    
















  

* Applicant must be a NAPNAP member.
To submit your application, please complete and return this form, an current curriculum vita, and a one-two page summary of your experience. The summary should include:

  • Three sentence description that you would like used in any publication when they acknowledge your contribution.
  • Description of past media experience (include print and video experience) and the capacity (quoted in an article, wrote an editorial, provided background comment, participated in broadcast video, etc).
  • Description of past authorship experience.
  • Description of your area(s) of expertise and why you consider yourself well versed in the specific topic area.
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