Membership Application

Membership Application 

New Member__________        Renewal: _________  

NAME/CREDENTIALS:_________________________________________________________ ADDRESS:____________________________________________________________________ CITY/STATE/ZIP:______________________________________________________________ PHONE:______________________________________________________________________ EMAIL:_______________________________________________________________________ EMPLOYER:__________________________________________________________________ ADDRESS:____________________________________________________________________ CITY/STATE:__________________________________________________________________ PHONE:______________________________________________________________________ EMAIL:_______________________________________________________________________ POSITION:____________________________________________________________________ PREFERRED ADDRESSES FOR MAIL OR E-MAILS? HOME: _______ WORK: _______ Remember: All monies are due by the date of the Annual Program Check appropriate line below: ________I wish to join the WVLN as a Nurse Educator  

________I wish to join the WVLN as a Consumer  

________I wish to join the WVLN as a Community Nurse  

________I wish to join the WVLN as a (please specify) ______________________  

Dues (Only) $50.00  

Contribution: ________  

TOTAL Enclosed: ________ (Make check payable to WVLN)  

SIGNED: ______________________________________________________DATE:__________________  

In addition, if you have any suggestions for presenters or topics for our Faculty Development Programs we would appreciate hearing what they are: ________________________________________________________________________  

We look forward to your active membership in this worthwhile organization.  

Please mail application and dues to:

Tammy Minor  

3787 Blue Sulphur Road  

Ona, WV, 25545