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Downloadable Membership Application
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Membership eligibility is dependent on having an RN license in good standing

 

Membership Application / Renewal

(Incomplete or illegible applications will not be processed)

 

 

Member Name: _________________________________________________ Date:__________________________

 

Please indicate if this is a _____ new membership or ___ renewal.

 

Preferred mailing address: __________________________________City/State______________________________

 

Zipcode _______________ County ___________________________

 

(Unless otherwise requested, members will be assigned to Regions based on County of preferred mailing address.)

 

Home telephone number: (_____ ) ______-_______                Cell Telephone Number: (____) ____-______

 

Work telephone number:  (______) ______-_______                Fax Number: (____) _____- _______

 

 

Preferred email address: ________________________  Alternate email address: ________________________

 

(All communication from CAPNI is by email)

 

Degrees / Designations: _____________________________________

 

Certifications: _____________________________________________

 

Practice Specialty: __________________________________________

 

Employer: _________________________________________________

 

 

Payment Information

 

___  Active Professional - $125

___  Student - $50

 

(Note: In accordance with the Internal Revenue Service Code and related regulations, we estimate that 55% of your dues are non-deductible, political expenditures.)

 

Payment Method:

 

___ Check

                Name on check: ______________________________________Check Number:_______

 

___ Visa (A $3.00 handling fee will be applied to credit card payments.)

                Cardholder’s Name: ____________________________________ (as it appears on front of card)

                Card Number: _________________________________________

                Card Code: ______________ (3 digit number on back of card)

                Expiration date: ______________

 

___ Mastercard (A $3.00 handling fee will be applied to credit card payments.)

                Cardholder’s Name: ____________________________________ (as it appears on front of card)

                Card Number: _________________________________________

                Card Code: ______________ (3 digit number on back of card)

                Expiration date: ______________

 

Completed forms can be mailed to:

CAPNI
PO Box 87925

Canton, MI  48187

 

 

 

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Calendar

3/23/2017
Region 3 March Program