Application for Membership in the Mississippi Nurses Association

Last Name / First Name Middle Initial ________________________________________________
		Mail to:
Street or P.O. Box _______________________________________________________________	MS Nurses Association
		31 Woodgreen Place
City, State, Zip ____________________________________	County___________________	Madison, MS 39110
		Telephone: 898‑0670
Social Security Number _____________________________	Home Phone ______________	Fax: 898‑0190

Work Phone ____________________  Employer Name _________________________________	mna@netdoor.com

Employer Address ____________________________ Area of Practice _____________________	Please make checks payable to MNA.
		
Basic School of Nursing _______________________ Highest Degree ______________________

Graduation: Month, Year  ______________________ State RN License # ___________________

Recruited By ___________________________________________________________________	
	
MEMBERSHIP DUES ‑ circle one
Q Monthly Bank Draft Plan
	In order to provide for convenient monthly membership payments, this is to authorize withdrawal of 1/12 of my annual dues from my checking account each month on the 15th day of the month In the amount of $16.17 which Is designated and maintained as shown by the enclosed check made payable to MNA.
	MNA is authorized to charge this amount by giving the undersigned thirty (30) days written notice. The undersigned may cancel this authorization upon receipt by MNA of a written notIfIcatIon of termination twenty (20) days prior to deduction date as designated above.

Authorization Must Be Signed ____________________________________________________________

Q Payroll Deduction Plan
This plan Is available only where there Is a agreement between the employer and MNA. Contact the employer or MNA for more information. If approved, I understand that $15.83 will be withdrawn monthly from my paycheck.

Authorization Must Be Signed ____________________________________________________________

Q  FULL DUES	$190.00	Q  REDUCED DUES	$95.00		Q SPECIAL DUES	   $55.00
Annual		Annual (1st yr)			Annual
- Employed full‑time				    - Unemployed RN			   - 62 years or older & not employed
                            OR
 - Employed part‑time				    - Full Time Grad. Student (9hrs)		   - Totally disabled
				   - New Grad. From basic school of nsg.
					(within 6 months of grad.)
-  62 years + & and earning more 
					than SS allows
Please enclose check				Please enclose check			Please enclose check
				
Q FULL DUES	$16.17	Q REDUCED DUES	$8.25	Q SPECIAL DUES	$4.92
Monthly Bank Draft		Monthly Draft (1st year)		Monthly Bank Draft
- Employed full‑time				    - Unemployed RN			   - 62 years or older & not employed
                            OR
 - Employed part‑time				    - Full Time Grad. Student (9hrs)		   - Totally disabled
				   - New Grad. From basic school of nsg.
					(within 6 months of grad.)
-  62 years + & and earning more 
					than SS allows
Please complete the Monthly Bank Draft Plan	Please complete the Monthly Bank Draft Plan 	Please complete the Monthly Bank Draft Plan
above this box and enclose a check	above this box and enclose a check	above this box And enclose a check

Q Bank Card Payment: Available for Annual Payments ONLY			_____ Visa  	____ MasterCard

	Card # _______________________________ Expiration Date ____________________ Signature __________________________________________________________

Mississippi 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 MNA (30%) Is not deductible as a business expense. Note: $7.50 of MNA member dues Is for a subscription to The American Nurse. $14.00 Is for a subscription to the American Journal of Nursing. $18.00 is for a subscription to The Mississippi RN.				Revised 11/24/97