Missouri Association of RN First Assistants

(Before you Print)

Membership Form

Name: _______________________________ RN License #:___________________

Address: ____________________________________________________________

City: ________________________________ State: ______ Zip: __________ - ____

Home Phone: (____)__________________ Home Fax: (____)__________________

Email: ______________________________________

Employer(s): __________________________________________________________

Address:_____________________________________________________________

Work Phone: (____)_________________ Work Fax: (___)_____________________

Pager:____________________________ Cellular: ___________________________

Are you certified?

CNOR: yes____ no____

CRNFA: yes____ no:____

Other: (please specify) __________________________________________________

Specialty: _________________________________________________________

Have you attended a formal RNFA program: _________________________________

Please circle any of the follow committees you would be willing to serve on:

Legislative,     Membership

Budget & Finance,     Nominating,    Audit

Education,     Public Relations & Fundraising

Membership dues: $30.00