MoSALPN Membership Application
NOTE: MoSALPN is now accepting payment through Paypal. Click here to access the Paypal version of this form.
To join MoSALPN, print this page and send with payment to:
MoSALPN
PO Box 105542
Jefferson City, MO 65110
Membership Application
Name __________________________________________________
Address ________________________________________________
City, State, ZIP ___________________________________________
(H) Phone _______________________________________________
(W) Phone _______________________________________________
Email _______________________________________________
Annual Fees:
_____ Regular Membership (LPN) $45.00
_____ Electronic Membership $40.00
_____ Lifetime Membership $500 - Entire amount to be paid within five(5) consecutive months; a member may pay a one-time fee to maintain membership their entire life, with all rights and privileges.
_____ Associated (Retired/Disabled 5yr. member) $20.00
_____ Sustaining Member (Non-LPN) $20.00
_____ Legislative Fund $5.00
I have enclosed my: _____ Check _____ Money Order
Positions You Are Interested In
Elected Positions
Officers BoD _____ Pres. Elect _____ Vice Pres. _____ Secretary _____
Committees(Meet at least once per year) | |
| Convention | ___________________________________________________________ |
| Finance | ___________________________________________________________ |
| ByLaws | ___________________________________________________________ |
| Ways & Means | ___________________________________________________________ |
| Legislative | ___________________________________________________________ |
| Membership | ___________________________________________________________ |
| Education | ___________________________________________________________ |
Biography | |
| Name | ___________________________________________________________ |
| Address | ___________________________________________________________ |
| Phone (home) | ___________________________________________________________ |
| ___________________________________________________________ | |
| Place of Employment | ___________________________________________________________ |
| Member of MoSALPN | Yes_____ Years of Membership____________________________ |
| Previous Positions Held with MoSALPN | ___________________________________________________________ |
| ___________________________________________________________ | |
| Place of Employment | ___________________________________________________________ |
Consent Form
I, ________________________________________________, hereby give my consent to have my name considered by the Nomination Committe for the office of __________________________. In the event that I am not chosen as a candidate for this office I would also be interested in being considered for one of these offices, ___________________________________________.
I attest that I am a current member of MoSALPN with the membership expiring ____________________________________.
Date _______________________________________ Signature _______________________________________