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Mary Mahoney Professional Nurses Organization

Proud of Our Past and Embracing Our Future

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Proud of Our Past
and Embracing Our Future

Membership Application

Thank you for joining MMPNO.

Membership is on an annual basis from September 1 – June 30. While you may join at any time, membership fees are not prorated.

Member Information
Name*
(include credentials)
Prefix First Last Suffix
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Cell
Email*
Sex
- Female
- Male
Birthday
Month and day
Experience & Education
Are you currently licensed as a nurse?*
If you are a licensed RN, membership dues are required.
- Yes
- Yes and I'm in nursing school
- No, I'm a nursing student
State currently licensed in*
Please indicate your nursing school*
(Note: A student (SN) is an unlicensed student in a nursing program)
Degree studying*
Year of graduation*
Do you want a mentor*
- Yes
- No
Highest degree held
- Diploma
- Associate Degree
- Baccalaureate in Nursing
- Masters in Nursing
- Masters in Other Fields
- Doctorate in Nursing
- Doctorate in Other Fields
Nursing employment
- Full-time
- Part-time
- Retired
- Unemployed
Employer's name*
Experience in nursing
- Less than 5 years
- 6-10 years
- 11-15 years
- 16-20 years
- More than 20 years
Primary work setting(s)
Please select all that apply.
- Inpatient
- Education
- Long Term Care
- Ambulatory
- Community Health
Other work settings
Please list
Positions held
Please select all that apply.
- Clinical
- Administration
- Research
- Education
- Informatics
- Quality Care
Other positions held
Please list
Membership in other professional nursing organizations
Please select all that apply.
- NBNA
- EBNOT
- SBNR
- ANA
- WSNA
- KCNA
- SNA
- NWONL
- WCN
- NLN
- AACN
- AMSUS
- Sigma Theta Tau
Other memberships (List)
Volunteer
You have a great opportunity to be involved with the organization.
Please identify your area or areas of interest.
- Mentorship (student or professional nurse in practice transition)
- Grant writing
- Program and professional development
- Tutor/academic support
List area of interest for tutor/academic support*
Committees
Please select all the committees you are interested in.
- Publicity/Membership
- Education
- Ways & Means (fund raising for student scholarships)
- Community Outreach (BP Screening, Special Projects, Support Community Projects)
- Endowment
- History
List other areas of interest
Annual Membership Dues
Student Nurse memberships are free.
Membership level*
- Active $100.00
- Retired $50.00
Payment choices*
- Check
- Credit Card
Credit Card*
Card Details
Cardholder Name
Make Check payable to Mary Mahoney Professional Nurses Organization or MMPNO and mail to Post Office Box 22003, Seattle, WA 98122-0003
Total
$0.00

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Contact

PO Box 22003
Seattle, WA 98122-0003

206-632-2524
president@marymahoney.org

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