NDNA Online Membership Form

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Apply or renew your application online. For those applicants that are renewing their NDNA membership, make sure you are logged into the site so that your information will be prepopulated on this form; check the vailidity of this information and press the CONTINUE button to make a payment. For those applicants that are new to NDNA, please fill in the information and press the CONTINUE button to ake a payment. In either case, a red * will appear for required fields.

Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

Address 1:

Address 2:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Toll Free:

Fax:

Practice Setting:

Employer:

Employer Address:

Position:

Bio:

Email:

Password:

Confirm Password:

Credentials:

SSN:

Basic School Of Nursing:

Year of Graduation:

RN Licence Number:

Recruited By:

Each NDNA member is entitled to membership in a nursing council, based on their area of employment or area of interest. Please indicate Council of your choice:

Membership Category Dues

PAYMENT SCHEDULE
Payment Plan	Monthly Electronic/Payroll	Annual Check/Credit Card
Full Membership	18.88	222.50
Reduced Membership	9.60	111.25
Special Membership	4.97	55.63

Full Membership

Employed

Reduced Membership

Retired/Not Employed

Full Time Student

New graduate from basic nursing education program, within two years after graduation (first membership year only)

62 years of age or over and not earning more than Social Security allows

Special Membership

62 years of age or over and not employed

Totally Disabled

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