This membership application collects an applicant's contact information, current employer details, whether they are currently an ANPD member, other professional organization memberships, who referred them to CANPD, and allows them to pay $30 annual dues with an optional scholarship donation. It provides a receipt section to be filled out and returned to the applicant upon processing of dues and donation.

1. Membership Application
2015 - 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 No
List other Professional Organization Memberships:
Referred to CANPD by:
Annual Dues*: $30.00
I optout 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:
CANPD
PO Box 525
Western Springs, Il 60558
__________________________________________________________
Receipt
Chicago Association for Nursing Professional Development
Annual dues $30 Check # Cash
Optional Scholarship Donation
(tax deductable)
$ Check # Cash
Member’s name:
Treasurer or Designate: Date: