| PHILIPPINE NURSES ASSOCIATION OF SAN DIEGO COUNTY, INC. P. O. Box 881114 San Diego, CA 92168 Phone: (619) 235-5502 Website: www.pnasd.org |
| MEMBERSHIP APPLICATION: | Date: __________________ Cash Check |
| NAME: _________________________________________________________ |
| (Last) | (First) | (Middle) |
| ADDRESS: | _____________________________________________________ |
| CITY: | _____________________________________________________ |
| STATE: | _______________________ ZIP CODE: _________________ |
| HOME PHONE: | ________________________________________________ |
| WORK PHONE: | ________________________________________________ |
| E-MAIL: | ________________________________________________ |
| DATE OF BIRTH (Optional): ______________________________________ |
| (Month) | (Day) |
| PRESENT EMPLOYER: | __________________________________________ |
| AREA OF EXPERTISE: | __________________________________________ |
| __________________________________________ |
| SCHOOL GRADUATED FROM: _______________________________________________________________ |
| Other personal information you wish to share: ______________________________________________________________________________________________________________________________ |
| Fee To Enclose: | $50.00 if you are a new or active RN $40.00 if you are a retired RN $35.00 if you are an LVN $25.00 if you are an RN or LVN student |
| Send to: | PNASD P. O. Box 881114 San Diego, CA 92168 |