TNA
 

 

TNN



Fill in the information. Print the form. Fax it to 512.452.0648. Or mail it (with check) to Texas Nurses Association,
7600 Burnet Road, Suite 440, Austin, TX 78757-1292.

Please direct any questions to 800.862.2022.

last name
first name
middle initial
home address
city
state
zip code
social security #
work phone
home phone fax
e-mail
county of residence
employer's name
dob
 (01/02/1900)



Dipl. ADN BSN MSN
school name
graduation month
and year
RN license number
state issued
degree(s)/credential(s) by initial
Dues of $99.00 include a subscription TEXAS NURSING ($9.00). Dues are not deductible as charitable contributions for tax purposes, but may be deductible as a business expense. However, the percentage of dues used by a state association for lobbying is not deductible as a business expense. Please check with TNA for the correct amount.


FRIEND/CO-WORKER (NAME)
CONFERENCE / WORKSHOP
WEB SITE EMPLOYER
OTHER (PLEASE SPECIFY) MAIL



MONTHLY electronic payment of $9.25 with CREDIT CARD. Please provide authorization signature, complete the credit card information below and your credit card will be debited a monthly amount on or after the 1st of each month. (A small service fee is included with dues)

MONTHLY electronic payment of $9.25 from CHECKING ACCOUNT. With the electronic dues payment plan (EDPP), your dues are automatically paid each month from your checking account; a small service fee is included in the monthly withdrawal. Please provide authorization signature and enclose a check with your mailed application for the first month's payment which will be drafted using the account designated by the enclosed check.

Authorization (to provide monthly electronic payments to Texas Nurses Network): 1) this is to authorize TxNN to withdraw 1/12 of my annual dues and any additional service fee from my checking account each month on or after the 15 th day of each month; 2) which is designated by the enclosed check for the first month's payment; 3) TxNN is authorized to change the amount by giving the undersigned thirty (30) days written notice; 4) the undersigned may cancel this authorization upon receipt by TxNN of written notification of termination twenty (20) days prior to deduction date as designated above. TxNN will change a $5.00 fee for any returned drafts.

signature ______________________________________________________ date _____________________

 

FULL ANNUAL PAYMENT of $99.00 by CREDIT CARD (please complete the credit card information below.)

FULL ANNUAL PAYMENT of $99.00 by CHECK (check made payable to Texas Nurses Network and mailed with application to Texas Nurses Association , 7600 Burnet Rd., Suite 440 , Austin , TX 78757-1292 )

please charge to my:
name on card:
card #:
expiration date:
signature:
___________________________________________________________
To be completed by TNA
District
Expiration Date: Month Year
Amount Enclosed
Approved by
Date