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Illinois Society for Advanced Nursing
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ISAPN Membership Application                             New Member      Renewal  
Referred By:
Name:
Street:
City:
State:
County:
Zip:
Home Phone:
Home Fax:
Email:+
APN License Number(s):
State of Licensure:
ISAPN Region #:

  Check here for region number.
Employer:
Job Title:
Street:
City:
State:
Zip:
Work Phone:
Work Fax:
Please check your preferred fax and e-mail in order to receive information from ISAPN. I authorize ISAPN to send faxes and e-mails to the below checked fax numbers(S) and email addresses.
Preferred Email: Home Work Preferred Fax: Home Work
State Legislative Districts Numbers: While this information is not required to process your application, ISAPN can better serve its members if we know the state legislative district in which you reside. You can find this information on your Voter's Registration Card or by going to www.ilga.gov.
Illinois House District #: Illinois Senate District #
APN Designation:
CNS CNM
CRNA CNP
Student APN Grad(past 12 months)
Clinical Specialty:
Dues Categories:

Please check the appropriate box for your membership category. In addition to your ISAPN dues, a voluntary assessment for the ISAPN PAC is included in a separate column. The ISAPN PAC contributes to political candidates who understand and support advanced practice nursing issues.
Membership Type
Dues
PAC
Total
Individual Member
Registered nurses licensed by Illinois law as advanced practice nurses.
$200
$50
$250
Advanced Practice Nursing Student
Registered nurses not currently licensed as Illinois APNs who are enrolled in an accredited program that prepares APNs for licensure.
$40
$50
$90
Associate Member
Registered nurses who are not advanced practice nurses and who are not enrolled in an accredited program that prepares RNs for Illinois licensure.
$100
$50
$150
Corporate Sponsor
Any entity interested in supporting ISAPN's goals.
$500
$50
$550
Advanced Practice Nursing Graduate (within last 12 months)
Send copy of diploma to ISAPN to qualify for this special rate.
$100
$50
$150


ISAPN PAC: Your annual membership dues include a voluntary ISAPN PAC assessment unless you indicate otherwise here.

I do not want to contribute $50 to the ISAPN PAC.

If you wish to contribute an amount other than $50, please specify here: $ Enter only numbers with no commas or decimal points.

A copy of our PAC report is available for purchase from the State Board of Elections in Springfield, Illinois.

Payment Options

Total Due $ (Dues and PAC payment).

 

Option 1 - Pay by Credit Card

To pay via secure on-line credit card processing please click the button to the left, you will be prompted for credit card information in the proceeding steps. Processing will be done securely through Verisign.

NOTE: This is the only option where your membership registration is submitted via the web. Options 2 and 3 MUST be printed out and mailed to ISAPN.

Option 2 - Pay By Check

Option 3 - Pay by Direct Debit

For those that have chosen the Individual Member Membership, you may chose the electronic dues payment plan of $19 per month plus a voluntary PAC contribution of per month

+ - You must enter an email address in order to receive a receipt for this transaction.

ISAPN, PO Box 1735, Springfield, IL 62705
866-GO-IL-APN or (866) 464-5276
Fax: 217-525-2842
info@isapn.org
© Illinois Society for Advanced Practice Nursing 2003-2005