SVN membership application October 1, 1994-September 30, 1995

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JOURNAL OF VASCULAR NURSING

JUNE 1996

SVN Membership Application October 1, 1995-September 30, 1996 For membership in The Society for Vascular Nursing, please complete the attached application and return it with a tax-deductible (as determined by law) check made payable to Society f o r Vascular Nursing. Dues are $75 (US and Canadian members) or $90 (International members) (US funds payable through a US bank only) p a y a b l e a n n u a l l y b y O c t o b e r 1 o f e a c h y e a r . Thirty-five dollars ($35) of the annual dues is applied toward a subscription to the quarterly Journal of Vascular Nursing.

Please type or print clearly and list name and credentials as you would like them to appear on membership certificate.

Name Home Address City Home Telephone (

State

Zip

State

Zip

Date

Signature

)

Employer Business Address City Business Telephone ( Preferred Mailing Address:

rl H o m e

O Business

Social Security No. Membership Category:

O Active

Highest Level of Education:

Doctorate ( p l e a s e s p e c i f y ) FIBS

O Associate

~1 BSN

{~ MS

O RN

[~ LPN

O MSN

El Other

Current Title/Position License Number

rq RN

~ LPN

State

Exp. Date

I consent to have the following telephone number published in the SVN Membership Directory (published in the Fall of each year):

(

)

Return to: SVN, 309 Winter Street, Norwood, MA 02062, (617)762-3630. Please Note: Most membership mailings are sent at the non-profit bulk rate. I f mailing address is incorrect or incomplete, mail is neither forwarded nor returned to our office. Thus we have no way o f knowing that you did not receive it. Please notify this office i f your address changes during the year. The Society cannot be held responsible f o r mail that is not deliverable.

FOR OFFICIAL USE ONLY

Received Date Paid Through Check No.

Amount Acknowledged