Dues: $25 Due Date: November 1, 2009

New Member _____ Renewal ______ (If renewing please include your name & only the

information that has changed since the last directory.)

Name:

Title/Degree(s):

Area(s) of expertise/specialties:

Work Address:

Dialysis Unit/Facility Name

Street Address

City State Zip Code

Work Phone: ( ) Fax: ( )

If you work at more than one location, please write the name, address, and phone number of each facility on the back of this page and check here .

Home Address:

Street

City State Zip Code

Home Phone: ( ) Fax: ( )

Email Address:

NOTE: Minutes and notices will be sent via e-mail. Directory in printed form will be mailed to you.

I would like to be included in the Website Membership Directory (password-protected and accessible only by members) Yes No

Are you a member of the National Kidney Foundation? Yes no

If yes, member # If no, visit www.kidney.org to join

Please send this form with $25 check payable to CRN to:

Catrina Morefield
39 Savona Ct.
Danville, CA 94526