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Click here - Vol. 11, Number 4

 

 

LPN State Only Membership Application

Online Application

Please fill out entire form before submission.

Contact Information

1. Full Name:
2. Credentials:
3. Today's Date: mm/dd/yyyy
4. Mailing Address:
   City:
   State:
   Zip:
5. Home Phone:
6. Email:

Personal Information

1. LPN License #:
   Years Experience:
2. Basic School of Nursing:
3. County of Residence:
4. NOTE: Please indicate the WVNA member who helped with your decision to become a member:
   

Employer Information

1. Employer:
2. Position:
   Department or Division:
3. Mailing Address:
   City:
   State:
   Zip:
4. Employer Phone:
5. Email:

1. Annual Dues: $149.00 or $12.52 monthly
2. WV Nurses-Political Action Committee
   Join the external political action committee for nurses. An additional $25 check should be made payable to WVN-PAC.
3. I would like to join the WVN-PAC

If you are a human, leave this field blank.