SE Minnesota ONS Chapter Membership Application

Requirements:

1.        RN, Student RN or Non-RN healthcare professional

2.        Member of ONS National

3.        Yearly dues $20.00 payable by March 31

4.        Late dues $25.00  

Name: _________________________________________________________________

              Last                                           First                                         MI 

Occupation: RN _________    Other_____________________ 

Highest Degree Obtained: AD______BAN/BSN ______ MS/MSN _______PhD______ 

Certification:   OCN______AOCN______AOCNS_______AOCNP______CPON_____ 

SIG Membership: _________________________________________________________ 

Preferred E-Mail:_________________________________________________________ 

Home address: ___________________________________________________________ 

Employer: _______________________________________________________________

Work address:__________________________________Phone:  Work ______________         

 Home Address__________________________________Phone Home_______________

Preferred mailing address:  Work_________    Home_________  

---Required Information---National ONS Member Number ______________ Expiration Date _______________

Membership status:  New _____________Renew ____________

Membership Category: Active________           Student________       

Senior (62 and older)________ Associate (Non-RN health care professionals)_______       

Please send dues and printed membership form to:

Becky Luckstein, Membership Chair, SE MN ONS Chapter, PO Box 414, Rochester, MN 55902, or Intra clinic to Becky Luckstein, Gonda 10E Mayo Clinic

 ****Please note dues paid by March 31 are $20. Dues paid after March 31 are $25.