LICENSED PRACTICAL NURSES ASSOCIATION OF ALABAMA
MEMBERSHIP APPLICATION
( ) New Application ( ) Renewal
Miss ( ) Ms. ( ) MRS. ( ) MR. ( ) DR. ( ) OTHER ( )
LAST: _________________________ FIRST: _________________________ MI: _____
STREET/PO#: ________________________________________ APT#: ________________
CITY: ___________________________________ STATE: __________ ZIP: __________
HOME PHONE: ( ) ____________________ WORK PHONE: ( ) ________________
EMPLOYER: _______________________________ FULL TIME ( ) PART-TIME ( )
SON GRADUATED FROM: ____________________ M/Y GRADUATED: ( )
LICENSE#: _______________________________ SSN: ____________________________
LPNAA ID#: ______________________________ DESIRED CHAPTER: ______________
A chapter must be selected. Call LPNAA for guidance.
MEMBERSHIP DUES:
( ) ACTIVE MEMBER .................................................................................................$ 40.00
( ) IN-ACTIVE MEMBER ............................................................................................$ 40.00
( ) PROVISIONAL MEMBER ......................................................................................$ 10.00
PLEASE MAKE CHECK / MONEY ORDER PAYABLE TO: LPNAA
MAIL APPLICATION TO:
MR. JAMES SELMAR, LPN
4013 RAY DR.
MONTGOMERY, AL. 36109
