ࡱ> MOLE@ 3bjbj .="8888```8<$@333#######$%&Rw($*!/3*!*!$883$"""*!"88#"*!#""":t#,p# |Q`L!# #$$0$# =)!=)#8888=)# 3,_"5I333$$`!`For Office Use: Return application to: District: Vermont State Nurse Association, Inc. Exp. 100 Dorset Street, Suite 13 Amt. Encl. South Burlington, VT 05403-6241 (802) 651-8886 Last Name/First Name/Middle Initial/Credentials Home Mailing Address Other Home Address City/State/ 9 Digit Zip Code Employer Name Employer Mailing Address Employer City/State/Zip code Membership Type Dues M Full Membership Dues $250.00 m Employed Full Time m Employed Part time R Reduced Membership Dues $125.00 m Not employed m Full-time student m New graduates from basic nursing education programs, during their second year of membership only. m Sixty-two (62) years of age or older and not earning more than Social Security System allows S Special Membership Rate $62.50 m Sixty-two (62) years of age or over and not employed; m Totally disabled. m New graduates from basic nursing education programs, within twenty-four (24) months of graduation, first membership year only. Payment Plan (check one box) m Full Annual Payment M: $250.00 R: $125.00 S: $62.50 m Check (To VSNA) m MasterCard or VISA Bank Card (Available for annual payment only) Bank Card Number and Expiration Date Signature for Bank Card  MEMBERSHIP APPLICATION Home Phone Number Social Security Number Work Phone Number Basic School of Nursing Home Fax Number Graduation (Month/Year) Work Fax Number RN License Number E-Mail License State Preferred Mailing address: Home m Work m Note: State nurses association dues are not deductible as charitable contributions for tax purposes, but may be deductible as a business expense. m Electronic Dues Payment Plan (EDPP) Amount includes service fee Circle correct amount. M: $21.17 R: $10.75 S: $5.54 Read, sign the authorization , and enclose a check for first months EDPP payment. The listed amount (21.17/10.75/5.54) will be deducted from your checking account on or after the 15th day of each month. 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 months payment. ANA is authorized to change the amount by giving the undersigned (30) days written not&=F# b k n     @ B  & , R ^ XZNPvNT  02!"#%>? h}U5CJh}U5CJOJQJjh}UUh}U5CJOJQJh}U5>*CJ h}UCJh}UCJOJQJ h}UCJ h}U5CJh}U h}U5B=# b i j k 0 2 l $d&dNP &dP$d&d NP ` @]`v333l n  : B  R n,ZjFvRT P^P`0^0 ^` 0^`0 0^0`.n  "$&=>?z{| &dP `^`` &dP$a$$d&dNP]DEBDF%&Z)\) `d)^`` d)&dPd) @^`@ @$d&dNP^`@ `^``"&DFH\&(p(r(((b))****** +"+@+B+t+v+++++++,,@,B,t,v,,,,,&-(-V-X----˽˲h}UCJOJQJUh}U h}UCJH* h}U5CJ h}U5CJ h}UCJh}U5CJOJQJ h}UCJ h}U6CJ h}UCJh}U5CJOJQJ h}UCJAice. The undersigned may cancel this authorization upon receipt by ANA of written notification of termination twenty (20) days prior to deduction date as designated above. Signature for EDPP Authorization Provision of the following information is optional, but helps us better serve the membership: Job Title Type of Position 0 m Researcher 1 m Administrator 2 m Consultant 3 m Supervisor (Manager) 4 m Educator 5 m Head Nurse (Manager) 6 m Staff Nurse 7 m Other (Specify) 8 m Nurse Practitioner 9 m Clinical Specialist 10 m Director of Nursing FA 11 m Health Policy Analyst 12 m Managed Care/Case Manager 13 m Quality Assurance 15 m Healing Arts Practitioner Work Setting 0 m Private Practice 1 m Hospital 2 m Nursing Home 3 m School of Nursing 4 m HMO/Free Standing Clinic 5 m Community/Home/Public 6 m School Nurse 7 m Occupational Health 8 m Office Nurse (Phys./De) 9 m Other (Specify) 10 m Ambulatory/Outpatient 11 m Business/Corporation 12 m Day Care 13 m Government Agency 14 m Home Health Care 15 m Hospice 16 m Quality/Utilization Re 17 m Respite Care 18 m Voluntary Association 19 m College Health 20 m Federal/Military 21 m Free Standing Surgery Education Completed: 1 m Diploma 2 m Associate Degree 3 m Baccalaureate in Nursing 4 m Baccalaureate in Other 5 m Master s in Nursing 6 m Master s in Other Field 7 m Doctorate in Nursing 8 m Doctorate in Other Field \)^)`)b)))))n*p****+<+p++++ ,<,n,,, -P- @^`@ @^@`$a$ &dPP------.F..../J/t///000^0z0001<1j1111$a$ @^`@------..J.L.......//N/P/z/|/////006080d0f000000011B1D1p1r111111122T2V2222222,3.3b3v333h}Uh}U56CJ h}U5CJ h}UCJh}UCJOJQJA112P2222(3v3333333 @^`@,...()()()..)() 0&P0P= /!*".#h$% P8$gDd)T  C 0Avt_logoliteb!Z;uR*?^Dn!Z;uR*?^PNG  IHDRG>%PLTEAVPUkTSRPOwtRNS@f cmPPJCmp0712OmIDATHDžUM{<mq*6(IܦBp~yyL<ɜ9>G;An˽[| eмp[7@{|3N&~8ŒMWLgnvKBefR$ *mn$2ȭ+;ΆltmJXw eJ?O:0M V+ b3/*K f0Ӊr̸r6ײgihp(M?MFX96 UR3] V8XZ@]kgiP *.64;xرLWu$˭)ޫEiS 䒔qcN5 WN"iqaD# B]҇=<$E&R3o ##nImd!PАΫzi?0&R<#W Z@B A Q(] #XMqO&e(PerYI+d3=sHA8*:bzee\TW$mg5(4ء}2u/tg\/|ʐW`ӿ@uuiqTNw`Y"u>'}㔭Ov"+7St0G=PZzi ږJ[ؗ g:2l&qK+}h^ΣQynYs2aEjF "(%Ê;h{nj$t/ ᨥƪP]~C1w_ .%#gn!_jc }Džc֌7Mc%8bY+cey{2rY[AǨ iC%[g*j/Ihdu{ceauecNaEA3U30%]t"_gxG,BT =*i"?ťQ['C#&IENDB`8@8 Normal_HmH sH tH L@L Heading 1$ @`@&``5CJ88 Heading 2$@&5BB Heading 3$d@&5CJ<@< Heading 4$@&5CJ Heading 5L$d@@& ; @` @ `  5CJOJQJDAD Default Paragraph FontVi@V  Table Normal :V 44 la (k@(No List 4@4 Header  !4 4 Footer  !PCP Body Text Indentp^`pCJ<B"< Body Textd5CJ@P2@ Body Text 2d5CJ@QB@ Body Text 3d5CJ$88<=#bijk67!` 7#;)*G^  "$&=>?z{|DEqr U m n Z [      9 > ? @   - G X m /0=Sas !=Xg89N[q"2345690008000p00 0000 000 000 000 00 00 0 00 00 0 00 00(0 0 0 0 0 0 080 0 0 0 000 0 0 0 0 0 0(0 00@00000000000000000000000000000H0000000000000000000000000000H00000000000000000000000000000H0z048@z08:0:0-3 l \)P-133,2$б!`[ii0 0e0e     A@  A5% 8c8c     ?A)BCD|E||@0(  B S  ?8_MH`MHuaMHbMH\cMH,ЦdMHeMHfMH܋gMH<hMH$WiMHjMH\kMH<lMH§mMH`#nMH\`#oMHpMHĹqMHԙrMHsMH SY22:p  xx9     aa9??s  ~9    = *urn:schemas-microsoft-com:office:smarttags PlaceName= *urn:schemas-microsoft-com:office:smarttags PlaceType>*urn:schemas-microsoft-com:office:smarttags PostalCode9*urn:schemas-microsoft-com:office:smarttagsState8*urn:schemas-microsoft-com:office:smarttagsCity9*urn:schemas-microsoft-com:office:smarttagsplace? *urn:schemas-microsoft-com:office:smarttags stockticker9*urn:schemas-microsoft-com:office:smarttagsphone:*urn:schemas-microsoft-com:office:smarttagsStreet;*urn:schemas-microsoft-com:office:smarttagsaddress $6651$$$o:ls phonenumbertrans    "4569")0OV "459333333333333"459VSNAVSNAVSNAVSNAVSNAVSNAVSNAVSNA jean grahamJeannie Graham)% u?" hh^h`OJQJo(w hh^h`OJQJo(wu?)%}U|]!"49@4|gg g 8`@` ` ````(@``0@`(UnknownGz Times New Roman5Symbol3& z Arial;WingdingsMGeoSlab703 MdCn BT"hFq&Fq&a!24d3H(?|]<For Office Use: Return application to:VSNAJeannie Graham  Oh+'0@ Xd    =For Office Use: Return application to:ip_or VSNAffiSNASNAVSNF Membership_applicationJeannie Graham_2anMicrosoft Word 10.0@@Zz@ Q@ Q՜.+,0$ hp|   f =For Office Use: Return application to: Title  !"#$%&()*+,-./0123456789:;=>?@ABCEFGHIJKNRoot Entry FpQPData 1Table'Q)WordDocument.=SummaryInformation(<DocumentSummaryInformation8DCompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q