Please Highlight, copy paste into a word document, print, complete and mail to: CCNDJI. PO Box 4556, Wheaton, IL 60189-4556
Name: _________________________________________________________
Address: _______________________________________________________
City: ______________________________ State: ____ Zip: ______________
Phone: _________________________________________________________
Email Address: ___________________________________________________
Fax: ___________________________________________________________
Parish: _________________________________________________________
Address: _______________________________________________________
City: ______________________________ State: ____ Zip: ______________
School of Nursing: ________________________________________________
Address: _______________________________________________________
City: ______________________________ State: ____ Zip: ______________
Place of Employment: _____________________________________________
________________________________________________________________
Business Phone: _________________________________________________
Birth Day: ________/__________ (month and day only)
RN _____ LPN _____ Lay Associate ____ Student _____
New Member __________ Renewal __________
I agree to allow my name to be printed in the membership directory.
Yes __________ No __________
I have enclosed the following amount for my annual dues contribution:
RN/LPN Annual Contribution $25.00 _______
Student Annual Contribution $10.00 ________
Lay Associate Annual Contribution $20.00 ________
Please make check or money order payable to: CCNDJI
For further information please email council_of_catholic_nurses-joliet@outlook.com