Membership Application2015 - 2016

Name:       Credentials:      Employer:       Position:      Employer Address:      City:       State:       Zip:     Work Phone:       Work E-mail:      Home Address:      City:       State:       Zip:      Home Phone:       Home E-mail:      Preferred E-mail Address: Home Work

Are you an ANPD member? Yes NoList other Professional Organization Memberships:      

Referred to CANPD by:      Annual Dues*: $30.00I opt out of the scholarship donation. Optional Scholarship Donation: $      Total: $      Method of Payment: Cash Check #____ Make checks payable to: CANPD

*Dues are comprised of $20 membership and $10 Carmen Hovanec Scholarship.Mail completed form and payment to:

CANPDPO Box 525

Western Springs, Il 60558

__________________________________________________________Receipt

Chicago Association for Nursing Professional DevelopmentAnnual dues $30 Check #       CashOptional Scholarship Donation

(tax deductable)$       Check #       Cash

Member’s name:Treasurer or Designate: Date: