Membership Application

Date:06 February 2012 02:00:14 AM
New or Renewal:New Renewal
Member since:
First Name:
Last Name:
Address:
Town:
State:
Zip:
Email:
Home Phone #::
Employer:
Work Address:
Suggested Topics for
Future Meetings:
Certification Status CSN
NCSN
Non-Certified
Certification Received From:
Date of Issue:
Would you like to serve
on the Executive Board?		 Yes
No
Educational Status BA
BS
MA
MS
APN
Grade Pre-K
Elementary
Middle
High School
School Site Public
Private

Dues for 2011-2012

Membership Status: All members must meet at least one of the following criteria. Please check one:
Full / Active Member ($25) CSN who resides in or is employed by a Bergen County BOE
Associate Member ($25) Private RN engaged in other than public school BOE, former regular member no longer eligible for full membership or substitute school nurse
Retired Member (gratis) ***Please submit application to stay on mailing list

Make check payable to: BCSNA (no vouchers)
Please print membership form. Mark check number on form and remit with payment
Mail to: Beverly Walker
28 Wood Street
Rutherford, N.J. 07070

Remember form is not submitted unless you click the "submit" button above
Membership is "active" once check is received.

DUE BY NOVEMBER 1, 2011