MEMBERSHIP APPLICATION CHECKLIST: 2011
Please use this checklist to ensure a complete application.
- Curriculum Vitae
- Copy of diploma or degree
- Credentials Form
- Statement of Professional History
- Copy of current license(s)
- Copy of malpractice insurance face sheet
- $25.00 application fee.
- $150.00 membership fee. May be pain in 2 installments.
- Make checks payable to ECIHW.
- Return completed application to:
Catherine A. Lavoie, APRN, CEO
P.O. Box 1164
Litchfield, CT. 06759
Phone: 860-488-1919