S&NMove

Nurses & Students on the Move
(Secure Form)

Name:
Address:
City:
State: Zip:
Phone: Email:
School (if registering as a student):
 Sophomore           Senior        RN to BSN
 Junior                  Graduate

Fee enclosed (includes snack and materials):
 $12 Student
 $17 TNA Member
(ID No. or SSN: )
 $22 Nonmember
 $ Group Total
    
For group registration, indicate number and    type complete list of students in this box:

Payment

    Mastercard
    Visa
    American Express
    Discover
Acct. # (include no spaces or hyphens)
Exp. Month  JanFebMarAprMayJunJulAugSepOctNovDec      Exp. Year  2001200220032004200520062007
    Check-  Fill out and print form and mail with your check to: TNA, 545 Mainstream Dr., Ste. 405, Nashville, TN 37228.  We cannot reserve your space until payment is received.

Total Amount  $

 Please check here and indicate if you require any special auxiliary aids or services: