Application for Membership

Send to:
Emergency Nurses Association
915 Lee Street
Des Plaines, IL 60016-6569
fax (847) 460-4001

Name: ________________________ Social Security Number: __________________

Street Address: _______________________________ Apartment:_______________

City:_____________________ State: ____ Zip/PC:________ Country: ___________

Email: ___________________

Home Phone Number: _______________ Work Phone Number:_________________

Licensure/Job Title:__________________

ENA Chapter Code: (Circle One)

Metro Baltimore Chapter - Code 011
Mid Maryland Chapter - Code 004
Eastern Shore Chapter - Code 270
Western Maryland Chapter - Code 012

Sponsor (Optional): _______________________ Sponsor ID: ___________________

Membership Categories: (Circle One)

Active Membership - A Registered Nurse committed to the advancement of emergency nursing.
1 Year - $96.00
3 Years - $240.00
5 Years - $360.00
Lifetime - (priceless) $1,200.00

Affillate Membership - A Licensed Practical Nurse (LPN), a Licensed Vocational Nurse (LVN), an Emergency Medical Technician (EMT), a student, or a member of another allied health field committed to emergency care.
1 Year - $57.00

International - An individual residing outside the United States or Guam who meets the qualifications for the Active member category.
1 Year - $86.00

Military Member (APO, FPO addresses only)- An individual currently serving in the military who uses an APO or FPO mailing address and meets the qualifications of the Active member category.
1 Year - $86.00

Retired/Disabled Member - An individual member who meets the qualifications of the Active member category and is retired from nursing.
1 Year - $57.00

RN Nursing Student - An individual enrolled in a RN nursing program
1 Year - $48.00

Nursing Student - NSNA Member- An individual enrolled in a RN nursing program who is a member of the National Student Nurses Association
1 Year - $36.00

Emergency Nurses Association Foundation
The Emergency Nurses Association has established a Foundation to enhance the quality of emergency care available to the public through research and education. The Foundation seeks to increase the level of emergency-related research and educational activities through grants, corporate sponsorships, and ENA membership support.

Optional Tax Deductible Gift to ENA Foundation (circle one)
100.00
50.00
25.00
10.00
Other Amount _________

Please indicate a Method of Payment: (circle one)
Check
VISA
MasterCard
Discover
American Express
(If paying by credit card, fill out credit card information shown below.)

Credit Card Number: _____________________ Expiration Date: _______________________

Name on Card: __________________________

DUES TOTAL: $ ___________

Thank you for joining the ENA!