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
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
License Number / State
The ‘Nursing Voice’ c/o ANA\C 1121 L Street, Suite 409 Sacramento, CA 95814
_________________________________________________ Employer Name
______________________ Business Phone
______________________ Business Fax
______________________ Postal Code
_________________________________________________ Employer City / State
_____________________________________________ E-mail Address
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a check for first month’s EDPP payment (contact your SNA/DNA for appropriate rate). 1/12 of your annual dues will be withdrawn from your checking account each month in addition to a monthly service fee.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
SNA membership # ______________
Reduced Membership Dues–$127.50
Full Time Student
New graduate from basic nursing education program, within six months after graduation (first membership year only)
62 years of age or over and not earning
more than Social Security allows
Special Membership Dues–$63.75
62 years of age or over and not employed
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.
Sponsor, if applicable
TO BE COMPLETED BY SNA
Employer Code ____________________________
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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