MCIRN Prime NP Application

The following information will be used to select participants for the MCIRN Prime NP Program. We reserve the right to select applicants based on the stated criteria and those who, based on the information presented, may make the biggest impact on the nursing workforce

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1. Name (Required.)

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2. Email address (Required.)

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3. Phone Number (Required.)

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4. Address: (Required.)

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5. City of Employment (Required.)

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6. State of Employment (Required.)

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7. Are you a nurse practitioner? (Required.)

Yes

MCIRN Prime NP Application

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* 1. Name (Required.)

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* 2. Email address (Required.)

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* 3. Phone Number (Required.)

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* 4. Address: (Required.)

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* 5. City of Employment (Required.)

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* 6. State of Employment (Required.)

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* 7. Are you a nurse practitioner? (Required.)

1. Name (Required.)

2. Email address (Required.)

3. Phone Number (Required.)

4. Address: (Required.)

5. City of Employment (Required.)

6. State of Employment (Required.)

7. Are you a nurse practitioner? (Required.)