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Application for Membership
in the
Utah Nurses Association
  
Please print this form, fill it out, and mail it to UNA. The address is at the bottom of the page.


Today's Date:
Last Name/First Name:
Credentials:
Street Address:
City / State / Zip:
Home Phone:
Home Fax:
Work Phone:
Work Fax:
Email Address:
Employer
Employer Address:
City / State / Zip:
Social Security Number:
RN License # and State:
Basic School of Nursing and Year Graduated:
Referred By:

Membership Categories

Full Membership:
Employed full or part-time		 Reduced Membership:
Not-employed: full-time student; or new graduate within six months after graduation from basic nursing education program.
FIRST MEMBERSHIP YEAR ONLY		 Special Membership:
62 years of age or over and not employed, or totally disabled

PAYMENT OPTIONS (Choose Either Annual or Monthly)

Annual Payment:

Full $200/ year
Reduced $ 100 / year
Special $50 / year
Annual Payment Method:
Check Enclosed
VISA
MASTERCARD
Card Number:
Expiration Date:
Details
Annual memberships expire one year from the month in which a member joins.

Monthly Payment:
(Electronic Funds Transfer from Checking)

Full $ $16.99 / month
Reduced $ 8.66 / month
Special $4.50 / month
Details The ANA will automatically deduct membership dues from your checking acccount. Dues transfer on approximately the 15th of each month. A check must be submitted, payable to UNA for first month's amount to initiate transfer. Dues deductions will continue on a month-to-month basis until UNA/ANA receives notification to stop deductions.

ANA is authorized to change the amount giving the above - signed thirty (30) days written notice. You may cancel authorization upon receipt by ANA of written notification of termination twenty (20) days prior to deduction date as designated. A $4 service charge is included in figuring monthly payments. By signing this form, I agree to these conditions.
Signed:


MAILING LISTS

Frequently mailing addresses are requested from UNA / ANA. If you are not interested in receiving information about various activities being offered to professional nurses via these mailings, please indicate below.
I do not wish to have my address on mailing lists

BECOMING A FRIEND OF UNF

 I would like to receive further information about the Utah Nurses Foundation; an organization dedicated to awarding scholarships and research awards to nurses in Utah since 1979.


Please print this form and mail it with your payment to:
Utah Nurses Association
3761 South 700 East, Suite 201
Salt Lake City, UT 84106

Thank you for joining the Utah Nurses Association!

We have a Vital Purpose!