Associate Membership Membership Application - Non Collective Bargaining Member 2024 Associate, Retired, and Student Membership Application for Monthly EFT Payors via ACH Membership Type*AssociateRetiredStudentName* First Last Degrees* Last 4 Digits of SSN* 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 Phone*Email* Enter Email Confirm Email Employer* US Citizen?* Yes No Date of Birth* Month Day Year RN License Number* License State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingBasic School of Nursing* Month and Year of Graduation from Basic Nursing Program* Member dues include ONA dues. One dollar ($1.00) per month of your dues goes to an account set up to support ONA’s political efforts. 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 call us at 614-969-3800 or email support@ohnurses.org. ONA dues are not deductible as a charitable contribution for federal income tax, but can be partially deductible as a business expense. A percent of the dues not deductible is calculated each year based on the amount spent lobbying. When preparing your taxes, contact ONA for the percentage that is deductible in the year you make this payment. ONA dues are nonrefundable. Your category from the list below determines your dues amount. ACH Annual Charge Price: Annual Associate Member Dues Price: Annual Retired Member Dues Price: Annual Student Member Dues Price: Associate Monthly Deduction Price: Retired Monthly Deduction Price: Student Monthly Deduction Price: Monthly payments are automatically deducted via ACH from your checking or savings account. By signing up for this payment plan, you authorize ONA to withdraw monthly dues payments via ACH on or after the 15th day of each month from your checking or savings account. The amount deducted includes a 33 cent service fee. ONA is authorized to change the amount withdrawn by giving you (30) days notice. You may cancel this authorization upon receipt of ONA of written notification of termination twenty (20) days prior to the deduction date designated above. ONA will charge a $15.00 fee for any returned ACH transactions.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.CommentsThis field is for validation purposes and should be left unchanged. Δ