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April, May, June 2010

ANA\C The Nursing Voice • Page 11

Membership and Communication

American Nurses Association \ California Membership Application

Help us stay in touch:

Do you have a new address or e-mail address?

_________________________________________________ Last Name/First Name/Middle Initial

______________________ _____________________

Credentials

Date of Application

_________________________________________________ Mailing Address

______________________ _____________________

Apt. / Unit Number

Home Phone Number

You can help American Nurses Association\California ‘stay in touch’ by updating your contact information. Call ANA\C at 916-447-0225, e-mail us a anac@ anacalifornia.org or return this form to:

_________________________________________________ City / State

_________________________________________________ Basic School of Nursing

P o s t a l C o d e Z i ______________________ _____________________ p Home Fax Number

______________________ _____________________

Year Graduated

License Number / State

The ‘Nursing Voice’ c/o ANA\C 1121 L Street, Suite 409 Sacramento, CA 95814

_________________________________________________ Employer Name

______________________ Business Phone

_________________________________________________ Title/Building/Department

______________________ Business Fax

_________________________________________________ Address

______________________ Postal Code

_________________________________________________ Employer City / State

_____________________________________________ E-mail Address

_________________________________________________

Referred By:

Payment Plan (Check One) Full Annual Payment Check Master Card or VISA Bank Card (Available for Annual payment only)

Payment Plan (continued) Electronic Dues Payment Plan (EDPP) Read, sign the authorization, and enclose a check for first month’s EDPP payment (contact your SNA/DNA for appropriate rate). 1/12 of your annual dues will be withdrawn from your checking account each month in addition to a monthly service fee.

_______________________________ Bank Card Number and Expiration Date

_______________________________ Signature of Card Holder

AUTHORIZATION to provide monthly electronic payments to American Nurses Association (ANA) This is to authorize ANA to withdraw 1/12 of my annual dues and any additional service fees from my checking account designated by the enclosed check for the first month’s payment. ANA is authorized to change the amount by giving the undersigned thirty (30) days written notice. The undersigned may cancel this authorization upon receipt by ANA of written notification of termination twenty (20) days prior to the deduction date as designated above. ANA will charge a $5.00 fee for any return drafts.

Mail with payment to: American Nurses Association\California 1121 L Street, Suite 409 Sacramento, CA 95814

________________________________ Signature for EDPP Authorization

MEMBERSHIP DUES VARY BY STATE

Membership Category (Check one) M Full Membership Dues–$255

  • Employed–Full Time

  • Employed–Part Time

$ _______________________________

AMOUNT ENCLOSED

CHECK #

SNA membership # ______________

R

Reduced Membership Dues–$127.50

  • Not Employed

  • Full Time Student

  • New graduate from basic nursing education program, within six months after graduation (first membership year only)

Grad. Date

_______________________

  • 62 years of age or over and not earning

more than Social Security allows

S

Special Membership Dues–$63.75

  • 62 years of age or over and not employed

  • Totally Disabled

Note: $7.50 of the SNA member dues is for subscription to The American Nurse. A percentage of your dues may or may not be applied to an SNA/DNA subscription. State nurses association dues are not deductible as charitable contributions for tax purposes, but may be deductible as a business expense. However, that percentage of dues used for lobbying by the SNA is not deductible as a business expense. Please check with your SNA for the correct amount.

Approved by____________

Sponsor, if applicable

____________

Expiration Date

______ Month

/

_______ Year

_______ _______

_______

STATE

DIST

REG

TO BE COMPLETED BY SNA

Employer Code ____________________________

Date

______

ANA\C Member Identification No. (if applicable) ___________________________________________ Name: _____________________________________ New Address: _______________________________ ___________________________________________ ___________________________________________ Old Address: ________________________________ ___________________________________________ ___________________________________________ New E-mail Address: _________________________

*** This is not to update your license information with the Board of Registered Nursing. Go to www.rn.ca.gov

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Registered Nurses

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Fax Resumes to 775-945-0732 ATTN: Mt. Grant General Hospital HR Dept or Email Resumes to mgghjobs@yahoo.com or call collect 775-945-2461 for more info.

Do you know where your nursing career is going?

Or which direction to turn?

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Looking for an exciting place to work where you have the opportunity to help others?

SEEKING CARDIOVASCULAR OR NURSES

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t

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