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 InformationName*(include credentials) Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Suffix Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*CellEmail* SexFemaleMaleBirthdayMonth and dayExperience & EducationAre you currently licensed as a nurse?*YesYes and I'm in nursing schoolNo, I'm a nursing studentState 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*YesNoHighest degree held Diploma Associate Degree Baccalaureate in Nursing Masters in Nursing Masters in Other Fields Doctorate in Nursing Doctorate in Other Fields Nursing employmentFull-timePart-timeRetiredUnemployedExperience in nursingLess than 5 years6-10 years11-15 years16-20 yearsMore than 20 yearsPrimary work setting(s)Please select all that apply. Inpatient Education Long Term Care Ambulatory Community Health Other work settingsPlease listPositions heldPlease select all that apply. Clinical Administration Research Education Informatics Quality Care Other positions heldPlease listMembership in other professional nursing organizationsPlease select all that apply. NBNA EBNOT SBNR ANA WSNA KCNA SNA NWONL WCN NLN AACN AMSUS Sigma Theta Tau Other memberships (List)VolunteerYou 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*CommitteesPlease 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 interestAnnual Membership DuesMembership level*Active $100.00Retired $50.00Student Nurse (organization participation) $0.00Payment choices*CheckCredit CardNo payment - student memberCredit 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 98122-0003Total $0.00