TNA Member-Get-A-Member Enrollment Form
New Member Information
Last Name___________________ First Name_______________ MI _____
Address______________________________________________________
City____________________________ State______ Zip_______________
Social Security Number_______-_____-__________
Employer_____________________________________________________
Home Phone( ) -_______ Work Phone( ) -________
Cell Phone( ) -_______ Pager Phone( ) -_________
County of Residence_____________ RN License #___________________
Academic Degrees__________________Credentials__________________
Email Address________________________________________________
Payment OptionsMonthly Bank Draft authorization. Enclose a check for the first
payment of $22.00 (payable to TNA). This authorizes ANA to withdraw
1/12 of the annual dues from my checking account ($22.00 on or after
the 15th day of each month) which is maintained as shown on the
enclosed check for the first month’s payment. ANA is authorized to
change the amount by giving the undersigned thirty (30) days written
notice. The undersigned may cancel this authorization upon receipt
by ANA of written notification of termination twenty (20) days prior to
the deduction date as designated above.
Signature __________________________________________________
Payment in full by check. Enclose check payable to TNA for $260
Payment in full by credit card:
Visa 
Mastercard 
Discover American Express
Number_________________________________ Exp. Date __________
Sponsor Information
TNA Member’s Name ___________________________________________
ANA ID or Social Security Number ________________________________
To Be Completed by TNA Staff
Membership Status New Renewal Reinstated
State ____ Month ____ Year ____ District ____ Amt Enclosed $_________
Date ___________ App. by ___________________________________________
Mail this form with payment to the address listed below: