AACN Delmarva Chapter Membership and Discounted Bulk Membership

AACN Delmarva Chapter Membership and Discounted Bulk Membership

The following information must be completed for your membership order to be processed.

Your Name:______

AACN Member Number (if applicable):______Exp____ RN License Number:______

Check if applicable: CCRN____ PCCN______CSC_____ CMC_____ Exp date______

Home Address:______

City/State/Zip: ______

Employer Name and Position: ______

Employer Address:______

City/State/Zip: ______

Preferred Mailing Address HOME EMPLOYER

Home Phone: ______Employer Phone:______

Fax Number: ______E-mail Address: ______

Referred by (Name):______Chapter Name: Delmarva

For referral incentives specify one only

Costs: (check all that apply)

□  AACN National Annual Membership w/ chapter discount $69 (you must be a chapter member to receive the discounted rate)

□  Delmarva Chapter Dues: $20 (check only)

□  Payment Method: (Make a check payable to AACN Delmarva Chapter)

______Enclosed is a check for the full amount of the memberships ordered.

TO TAKE ADVANTAGE OF THIS BULK DISCOUNT OFFER

RETURN COMPLETED ORDER FORM AND PAYMENT TO:

AACN Delmarva Chapter

PO Box 3629

Salisbury, MD 21802-3629

If you have questions regarding this offer, please call 800-899-2226 or email .

Membership Certificates will be mailed to you upon receipt of your order and full payment.

Annual membership dues includes a non-refundable payment for a one year subscription to Critical Care Nurse ($12.00) and the American Journal of Critical Care ($15.00)

Revised 04/05 1G