Membership Application Standard Member (Collective Bargaining) EmailThis field is for validation purposes and should be left unchanged.Select your Employer* Akron General Medical Center Alliance Community Hospital Ashtabula County Medical Center City of Cleveland Division of Health Coshocton Regional Medical Center Cuyahoga County Health Department Defiance Regional Medical Center (Full Time Rates) East Liverpool Hospital Geneva Medical Center Hillside Rehabilitation Center Hoxworth Blood Center Lima Memorial Hospital Mary Rutan Hospital Mercy Allen Medical Center Ohio State University Hospitals Ohio State University Hospital - Surgical Technologists Main Ohio State University Hospital - Bone Marrow Transplant Coordinator Ohio State University Hospital - Respiratory Therapists Ohio State University Hospital - Surgical Technologists Ambulatory Ohio State University Hospital - Surgical Technologists East OSU Transplant Nurses Salem Regional Medical Center Summit County Health Department Toledo-Lucas County Health Department Trinity East Medical Center Union Hospital University of Cincinnati Medical Center Visiting Nurses Association Notice* Checking this box indicates that I have read the notice for my workplace. Please review your the initial notices for your workplace hereName* First Middle Initial Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone #*Cell Phone #Work Phone #Work Fax #Personal Email* Enter Email Confirm Email Work Email Enter Email Confirm Email US Citizen?* Yes No Date of Birth* Month Day Year Last 4 Digits of SSN*RN License NumberLicense State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingBasic School of Nursing*Month and Year of Graduation from Basic Nursing Program*Ohio Nurses Association Membership Assessments and Dues Rates Collective bargaining membership assessments and dues include the ONA, AFT, AFL-CIO, and Local Unit fees. One dollar ($1.00) per month of your dues goes to an account set up to support ONA’s political efforts, if you are a U.S. Citizen. You may choose at anytime to opt out of this dues designation. Opting out does not reduce the dues amount. If you are interested in opting out, please contact the Director of Governmental Relations and Political Advocacy at 614/365-9000. Non-U.S. Citizens are opted out automatically as required by Ohio law. Payment plan option can only be changed during December 1st through December 31st. If you have questions please contact the Membership Department at support@ohnurses.org. ONA dues are nonrefundable. The dollar amounts below represent the amount that will be deducted from your paycheck on a biweekly or monthly basis (depending on your workplace) or your checking account via ACH on a monthly basis.Bargaining Unit Hire Date* Month Day Year Employee ID #MEMBERSHIP AUTHORIZATION* YES, I want to join with my colleagues and become a member of the Ohio Nurses Association (ONA), AFT, AFL-CIO. I hereby request and voluntarily accept membership in ONA and I agree to abide by its Constitution and Bylaws. I authorize ONA to act as my exclusive representative in collective bargaining over wages, benefits, and other terms and conditions of employment with my employer. I wish to have my dues collected through the following mechanism:* Payroll Deduction Electronic Dues Payment Plan (EDPP) - monthly EFT via ACH from your checking or savings account Payment plan option can only be changed during December 1st thru December 31st. If you have questions please contact the Membership Department at support@ohnurses.org.Akron General Medical Center - Full Rate* Price: *biweekly payroll deductionAkron General Medical Center - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHAlliance Community Hospital - Full Rate* Price: *biweekly payroll deductionAlliance Community Hospital - Full Rate* Price: Electronic Dues Payment Plan - Monthly EFT via ACHAshtabula County Medical Center - Full Rate Price: Payroll DeductionAshtabula County Medical Center - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHCity of Cleveland Division of Health - Full Rate Price: Payroll DeductionCity of Cleveland Division of Health - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHCoshocton Regional Medical Center - Full Rate Price: Payroll DeductionCoshocton Regional Medical Center - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHCuyahoga County Health Department - Full Rate* Price: *biweekly payroll deductionCuyahoga County Health Department - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHDefiance Regional Medical Center Full Time - Full Rate Price: Biweekly Payroll DeductionDefiance Regional Medical Center Full Time - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHEast Liverpool City Hospital - Full Rate Price: Biweekly Payroll DeductionEast Liverpool City Hospital - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHGeneva Medical Center - Full Rate Price: Payroll DeductionGeneva Medical Center - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHHillside Rehabilitation Center - Full Rate Price: Payroll DeductionHillside Rehabilitation Center - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHHoxworth Blood Center - Full Rate Price: Payroll DeductionHoxworth Blood Center - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHLima Memorial Hospital - Full Rate Price: Biweekly Payroll Deduction (27 pay periods)Lima Memorial Hospital - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHMary Rutan Hospital - Full Rate Price: Payroll DeductionMary Rutan Hospital - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHMercy Allen Medical Center - Full Rate Price: Payroll DeductionMercy Allen Medical Center - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHOhio State University Hospital - Full Rate Price: Payroll DeductionOhio State University Hospital - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHOhio State University Hospital - Surgical Technologists Main Price: Payroll DeductionOhio State University Hospital - Surgical Technologists Main Price: Electronic Dues Payment Plan - Monthly EFT via ACHOhio State University Hospital - Surgical Technologists Main Price: Check or Credit Card (Annual)Ohio State University Hospital - Bone Marrow Transplant Coordinator Price: Payroll DeductionOhio State University Hospital - Bone Marrow Transplant Coordinator Price: Electronic Dues Payment Plan - Monthly EFT via ACHOhio State University Hospital - Respiratory Therapists Price: Payroll DeductionOhio State University Hospital - Respiratory Therapists Price: Electronic Dues Payment Plan - Monthly EFT via ACHOhio State University Hospital - Surgical Technologists Ambulatory Price: Payroll DeductionOhio State University Hospital - Surgical Technologists Ambulatory Price: Electronic Dues Payment Plan - Monthly EFT via ACHOhio State University Hospital - Surgical Technologists East Price: Payroll DeductionOhio State University Hospital - Surgical Technologists Ambulatory Price: Electronic Dues Payment Plan - Monthly EFT via ACHOSU Transplant Nurses - Full Rate Price: Payroll DeductionOSU Transplant Nurses - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHSalem Regional Medical Center - Full Rate Price: Payroll DeductionSalem Regional Medical Center - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHSummit County Health Department - Full Rate Price: Biweekly Payroll DeductionSummit County Health Department - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHToledo Lucas County Health Department - Full Rate Price: Biweekly Payroll DeductionToledo Lucas County Health Department - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHTrinity East Medical Center - Full Rate Price: Payroll DeductionTrinity East Medical Center - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHUnion Hospital - Full Rate Price: Payroll DeductionUnion Hospital - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHUniversity of Cincinnati Medical Center - Full Rate Price: Payroll DeductionUniversity of Cincinnati Medical Center - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHProduct Name Price: $43.85 Electronic Dues Payment Plan - Monthly EFT via ACHVisiting Nurses Association - Full Rate Price: Payroll DeductionVisiting Nurses Association - Full Rate Price: Electronic Dues Payment Plan - Monthly EFT via ACHDues Amount: $0.00 Your monthly dues payment (or biweekly - denoted with *) Note for UCMC Employees: All University of Cincinnati Medical Center (UCMC) employees must complete this form to start payroll deduction of dues. Your dues will not be payroll deducted unless this form is completed and returned. Click here to download the form Once completed, please upload the completed form below. You will not be able to proceed with the online application until the PDF is uploaded. UCMC Payroll Deduction Upload*Accepted file types: pdf, Max. file size: 2 GB. Payroll Deduction Authorization* I hereby request and voluntarily authorize my employer to deduct from my earnings and to pay over to ONA an amount equal to the regular monthly dues uniformly applicable to members of ONA. This authorization shall remain in effect and shall be irrevocable unless I revoke it by sending written notice via U.S. Mail to both the employer and ONA the period not less than thirty (30) days and not more than forty-five (45) days before the annual anniversary date of this agreement, or the date of termination of the applicable contract between the employer and ONA, whichever occurs sooner. This authorization shall be automatically renewed as an irrevocable check-off from year to year unless I revoke it in writing during the window period, even if I have resigned my membership in ONA. Monthly payments are automatically deducted via ACH from your checking or savings account. AUTHORIZATION to provide monthly electronic payments to Ohio Nurses Association (ONA): This is to authorize ONA to withdraw monthly dues payments via ACH on or after the 15th day of each month from my checking or savings account. I understand this amount includes a monthly service fee of 33 cents. ONA is authorized to change the amount by giving the undersigned thirty (30) days notice. The undersigned may cancel this authorization upon receipt by ONA of written notification of termination twenty (20) days prior to the deduction date as designated above. ONA will charge a $15.00 fee for any returned drafts.Name of Bank*Bank Account Number*Routing Number*Account Type* Checking Savings I authorize the Ohio Nurses Association to withdraw monthly dues payments via ACH on or after the 15th of each month from the account specified above.*If you agree, type your full name in this field.It is recommended on your behalf to print and keep this for your records. Δ
