Florida Association of
Nurse Assistants

Membership Application

Please Check One Item Below and fill in All Information
Individual or Supportive Membership Annual Dues - $30	_________
Retired Members/Student Members Annual Dues - $20	_________
Facility/Agency Membership Annual Dues - $200	_________
Corporate Membership Annual Dues - $500	_________

Name__________________________________ Date___________

Home Address__________________________________________

_______________________________________________________

City________________________ ST____ ZIP_________+_______

Home Phone_________________ Work Phone_________________

Fax____________________ E-mail__________________________

County__________________________

Employed By____________________________________________

Title___________________________________________________

Individual Members must include a copy of required certification and/or signature of DON, Supervisor or Administrator, sign below, to verify qualifications.

Signature__________________________________ Title_____________

Facility Contact Person________________________________________

Title__________________________________________

Print out this form and Mail with Check or Money Order To:

Florida Association of Nurse Assistants, Inc.
PMB #266
6039 Cypress Gardens Blvd.
Winter Haven, Florida 33884-4115