Recruitment

  Membership /Renewal Application

Please make check payable to:

FANA of Great Lakes, Inc

Mail to: P.O. Box 845

Bloomfield Hills, MI 48302-0845

Please check:  ____ RENEWAL   ____ NEW  

(Strictly non-profit and tax exempt 501C-3 status of professional nursing organization ID# 20-2524728)

Name ____________________________________________________________________________

Title _________________________________________ DOB ____________

Address (street) _________________________________________   Zip  ________________

Phone_____________________

Employer _____________________________________________________

Position ______________________________

Work Address ____________________________________________  

Work Phone _____________________________

School _________________________________________

Specialty ___________________________________________

E-mail _____________________________________   

Hobbies _______________________________________________

CATEGORY: (please check)

__ Regular $25.00

RNs__, LPN__, Nurse Practitioners__, MD’s__, Social Worker__, Pharmacist__,

Non-Medical Professional_____________________________

                   (Licensed at Any State or Country of origin)                              

__ Membership (lifetime) $250.00  (may be paid in installments)

__ Honorary Member $200.00

__ Corporate Sponsor $500.00

COMMITTEE INTEREST(S):

__ Membership                         __ Education & Practice            __ Charitable Project(s)   

__ Community Relations             __ Medical Mission                    __ Website