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