Membership Form Licensed Vocational Nurses Association of Texas
P.O. Box 143415, Austin, Texas 78714-3415
(210) 833-2768 or (979) 540-0265
www.lvnat.org
* Required
Membership Form
Type
*
New Member
Membership Renewal
If you are a member of a Division, List Division Name
Your answer
List Division #
Your answer
Type of Membership
Check type of membership
*
Active ($50)
Retired ($25)
Provisional ($10)
Institutional ($50)
Supportive ($20)
Field of Employment
The current field of employment
*
Hospital
Nursing Home
Private Duty Nurse
Office/Clinic
Other:
How were you referred to the LVN Association of Texas:
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Website
School
Employer
Friend
Other:
Employment Status
Current Employment Status
*
Nursing Full Time
Nursing Part Time
Unemployed/Retired
LVN
RN
Other:
Principle Employment
Current Principle Employment:
*
Your answer
City:
*
Your answer
County:
*
Your answer
State:
*
Your answer
ZIP:
*
Your answer
Does your employer provide you with group insurance?
*
Yes
No
What types of insurance are you most interested in?
*
Disability Income
Hospitalization & Major Medical
Malpractice
Life
Required
Member's Complete details + Contact details
Date:
*
MM
/
DD
/
YYYY
License # :
*
Your answer
Member Name:
*
Your answer
License Renewal Date:
*
MM
/
DD
/
YYYY
DOB:
*
MM
/
DD
/
YYYY
Address:
*
Your answer
City:
*
Your answer
Country:
*
Your answer
State:
*
Your answer
Zip:
*
Your answer
Email:
*
Your answer
Office ☎
Your answer
Home ☎:
*
Your answer
Fax 🖨:
Your answer
Notes
Contributions or gifts to this organization are not deductible as charitable contributions for income tax purposes.
However, dues payments may be deductible by members as an ordinary and necessary business expense.
Thank You!
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