West Virginia Nurse Newsletter

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Click here - Vol. 10, Number 2

 

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West Virginia Nurses Association Political Action Committee

Contribution Form

 

Personal Information:

Name:

 

Address:

 

City: State: Zip:

 

Home Phone: Alt. Phone:

 

Email Address: Birth Date :

 

Professional Information

 

Credentials:

 

Employer:

 

Title: Department:

 

Address:

 

Work Phone:

 

Donation Amount:

 

*Clicking submit will take you to PayPal, where you can make your electronic contribution.

 

 

*If your contribution is for $249 or more, please include your employer, title, department, address and work phone information.

 

"Please Disregard if Public Employee"