Create New User Account

Create New User

Provide your information below to create a contact record with AAPACN. Please provide your work address.

Fields marked with an asterisk (*) are required.

First Name

Last Name

E-mail (Cannot be generic or shared company email address)

Confirm E-mail

Create Password

Confirm Password

- Credentials
- Functional Role *
- Organization Category *
- Cell Phone
  
  Secondary Email
- Address Type
- Facility Name *
  
  Corporation Name (can be the same as the facility name) *
- Street Address *
- City *
  
  State *
  
  ZIP *
- Country
- Mail to Work Address (If "no," add separate mailing address below)
  
  Yes No
- Mailing Address (if different from above)
- Street Address
- City
  
  State
  
  ZIP
- Country
- Are you an RN or LPN? *
  
  Years of nurse leadership experience
- How did you hear about AAPACN? *
- If you selected "other," please specify:
  
  If you said a friend or colleague referred you, please tell us who:

Before creating your account we need to verify that you are a real person. To confirm that you are really seeing this screen please type the characters you see in this image into the box below it:

If you can't read the characters click here to generate a new image

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