2017-2018 nraa additional contact membership application
2017-2018 NRAA ADDITIONAL CONTACT MEMBERSHIP APPLICATION Membership Year - July 1, 2017 to June 30, 2018
This application is in accordance with the NRAA Bylaws An Active or Affiliate Member Company may identify unlimited additional contacts as part of their active membership. Become an Additional Contact today for your Member Company by filling out the information below. Company Name:
Primary Representative Information The Primary Contact is designated by the Member Company and is included with the annual dues. The Primary Contact may be changed on written notice to the NRAA Board of Directors. Only the Primary Representative for an Active Member can vote and is eligible to serve on the NRAA Board of Directors. Please list the current NRAA company representative for your company Name:
Title:
Additional Contact - $50 each Please attach names and contact information if you have more than one additional contact. Name:
Title:
Credentials: ____________________________ License Number (CNE/CME):___________________ Company Name: Address: City, State, Zip: Phone:
Fax:
E-mail:
Supplying your email address gives the NRAA permission to communicate with you via email.
Payment Information Enclosed is payment for ___ (#) of Additional Contacts @ $50 each. Check or money order is enclosed (payable to NRAA)
Amount: $ _______________
VISA
Amount: $ _______________
MasterCard
Amex
Credit Card #:
Exp. Date: _______________
Name on Card: Signature: For federal tax purposes, NRAA membership dues may be deductible as a business expense but not as a charitable contribution. In addition, 35% of dues are not deductible due to state and federal lobbying activities as defined by the IRS.
Mail with Payment to:
National Renal Administrators Association 100 North 20th Street, Suite 400 Philadelphia, PA 19103
Credit Card Applications may be FAXED to (215) 564-2175 If you have any questions about this application or your membership status, please contact NRAA headquarters at 215-320-4655 or [email protected]
Thank you for joining the NRAA! You will be contacted by our headquarters once you have been approved.
This application is in accordance with the NRAA Bylaws An Active or Affiliate Member Company may identify unlimited additional contacts as part of their active membership. Become an Additional Contact today for your Member Company by filling out the information below. Company Name:
Primary Representative Information The Primary Contact is designated by the Member Company and is included with the annual dues. The Primary Contact may be changed on written notice to the NRAA Board of Directors. Only the Primary Representative for an Active Member can vote and is eligible to serve on the NRAA Board of Directors. Please list the current NRAA company representative for your company Name:
Title:
Additional Contact - $50 each Please attach names and contact information if you have more than one additional contact. Name:
Title:
Credentials: ____________________________ License Number (CNE/CME):___________________ Company Name: Address: City, State, Zip: Phone:
Fax:
E-mail:
Supplying your email address gives the NRAA permission to communicate with you via email.
Payment Information Enclosed is payment for ___ (#) of Additional Contacts @ $50 each. Check or money order is enclosed (payable to NRAA)
Amount: $ _______________
VISA
Amount: $ _______________
MasterCard
Amex
Credit Card #:
Exp. Date: _______________
Name on Card: Signature: For federal tax purposes, NRAA membership dues may be deductible as a business expense but not as a charitable contribution. In addition, 35% of dues are not deductible due to state and federal lobbying activities as defined by the IRS.
Mail with Payment to:
National Renal Administrators Association 100 North 20th Street, Suite 400 Philadelphia, PA 19103
Credit Card Applications may be FAXED to (215) 564-2175 If you have any questions about this application or your membership status, please contact NRAA headquarters at 215-320-4655 or [email protected]
Thank you for joining the NRAA! You will be contacted by our headquarters once you have been approved.
