ANA Membership Activation Form

ANA Membership Activation Form
For dues rates and other information, contact ANA’s Membership Billing Department at (800) 923-7709 or e-mail us at [email protected]
Essential Information
First Name/MI/Last Name
Gender: Male/Female
Mailing Address Line 1
Credentials
Mailing Address Line 2
Phone Number
City/State/Zip
Email address
How did you hear about ANA?
County
Magazine
Online
Home
Work
Colleague
Mail
Other: __________________________
Professional Information
Employer
Current Employment Status: (ie: full-time nurse)
Type of Work Setting: (ie: hospital)
Current Position Title: (ie: staff nurse)
Required: What is your primary role in nursing (position description)?
Practice Area: (ie: pediatrics)
Clinical Nurse/Staff Nurse
Nurse Manager/Nurse Executive (including Director/CNO)
Nurse Educator or Professor
Not currently working in nursing
Advanced Practice Registered Nurse (NP, CNS, CRNA)
Other nursing position
Ways to Join
ANA and State Membership
ANA Only Membership
E-Membership
Membership Dues Dues vary by state. Visit JoinANA.org to check
dues rate in your state.
Dues Rate ...............................................................................$
Ways to Pay
Annual Payment
ANA-PAC Contribution (optional)...................................$
Check
Credit Card
ANF Contribution (optional) ............................................$
Monthly Payment
Total Dues and Contributions ..........................................$
Credit Card Information
Visa
Mastercard
AMEX
Discover
If paying by credit card, would you
Yes
like us to auto bill you annually?
Checking Account Attach check for first month’s payment.
Credit Card
Authorization Signatures
Credit Card Number
Expiration Date (MM/YY)
Monthly Electronic Deduction | Payment Authorization Signature*
Authorization Signature
Printed Name
Automatic Annual Credit Card | Payment Authorization Signature*
Please Note — $20 of your membership dues is for a subscription to The American Nurse and $27
is for a subscription to American Nurse Today. American Nurses Association (ANA) membership dues
are not deductible as charitable contributions for tax purposes, but may be deductible as a business
expense. However, the percentage of dues used for lobbying by the ANA is not deductible as a
business expense and changes each year. Please check with ANA for the correct amount.
*By signing the Monthly Electronic Payment Deduction Authorization, or the Automatic Annual
Credit Card Payment Authorization, you are authorizing ANA to change the amount by giving the
above signed thirty (30) days advance written notice. Above signed may cancel this authorization
upon receipt by ANA of written notification of termination twenty (20) days prior to deduction date
designated above. Membership will continue unless this notification is received. ANA will charge a $5
fee for any returned drafts or chargebacks. Full and Direct members must have been a member for six
consecutive months or pay the full annual dues to be eligible for the ANCC certification discounts.
Go to JoinANA.org to become
a member and use the code:
ANANW15
Fax
Web
Mail
Completed application with credit card
payment to (301) 628-5355
Join instantly online.
Visit us at JoinANA.org
ANA Customer & Member Billing
PO Box 504345
St. Louis, MO 63150-4345
Choose the way to pay that’s right for you, too
There are a variety of ways to pay for your membership at ANA.
Monthly Payments
Annual Payments
You can choose to pay your dues on a monthly basis – making
your dues no more than your lunch out! ANA will either charge
a credit card of your choice or deduct from your bank account
1/12 of your annual dues and any additional service fees. Bank
accounts are debited on or about the 15th and credit cards are
charged the first week of each month.
If you choose to pay annually, you can pay by credit card or a
check payable to ANA. If paying by credit, you also have the
option to have ANA automatically bill your annual dues each
month on your anniversary.
Online
You can join ANA instantly online.
Visit ANA at JoinANA.org and complete an online membership
application.
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Choose the membership that’s right for you
Our payment plans are easy and affordable. Select your membership and get involved today!
ANA & State Membership — See our rates on JoinANA.org
The “gold standard” of membership, this ANA membership also includes membership in your state nurses association.
You’ll receive full benefits from both, including valuable ANCC certification discounts. Plus, you’ll influence decisions
made at the national and state level that affect the practice of nursing and the health of our patients.
ANA Only Membership — $191.00 (or $16.42 per month)
ANA-Only members will receive full ANA member benefits but no state nurses association benefits. You’ll
have the chance to influence the decisions made at the national level that affect the practice of nursing and
the health of our patients. (Available in most states). Many states also offer State-Only membership. See your
state nurses association website for more information.
E-Membership Only — $45 per year
A web-only membership, this is our lowest cost option with limited benefits. Individual affiliate membership
is great if you want to access the Members Only section of nursingworld.org and support your profession.
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NO POSTAGE
NECESSARY
IF MAILED IN THE
UNITED STATES
Business Reply Mail
First-Class Mail
Permit No.7380
Postage will be paid by addressee
American Nurses Association
Membership Department
8515 Georgia Avenue, Suite 400
Silver Spring, MD 20910-3492
Silver Spring, MD