Massachusetts Nurses Association
LABOR PROGRAM. MEMBERSHIP. Massachusetts Nurses Association Revised May, 2017. Established 1903. APPLICATION 340 Turnpike Street Canton, MA 02021 Fax: 781-821-4445 Email: Safe Limits Massachusetts Nurses Save Lives Association PERSONAL INFORMATION. Name:___________________________________ _________________ RN or Professional License Number* __________________________. Address: __________________________________ City: ___________________________________ State: __________ Zip:_____________. Home Telephone: ___________________________ Cell: __________________________ Work: ___________________ Ext: ____________. Email address: ________________________________________ ________________________________________ ______________________. DOB: ____________________ Gender: ________________ Ethnicity: ________________Country of Origin: ___________________________.
PAYMENT AUTHORIZATION Please complete information below: m Credit Card/debit Card Please charge my: m Mastercard m Visa m American Express m Discover I hereby authorize and request the Massachusetts Nurses Association (MNA) to effect payment for any amounts owing by me to the MNA as
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