Membership Application

SOUTH DAKOTA
ORGANIZATION OF NURSE EXECUTIVES

Address: Sioux Falls, South Dakota 57106
email: marie.rogers@sanfordhealth.org

Type of application: *	New Application Renewal Cancel Membership Address Change
Name: *
Date: *
Work Email: *
In an effort to reduce mailing expense, you will receive SDONE communication via email (at your workplace). If you do not have an email address, mailings will be done.
Changes from last year?:	If no changes from last year check here (no need to complete rest of application).
Home Address:
Phone:
City/State/Zip:
Email:
Employing Institution/Agency:
Employer's Phone:
Employer's Address:
Employer's Email:
Employer's City/State/Zip:
Employer's Fax:
Your Title:
# Years in Position:
Educational Background:	Masters BS or BSN Associate Degree Diploma Other
Certification:
Are you an AONE member?:	Yes No
Name of SDONE member that brought you to the organization:
$50.00 Annual Dues, If you are a New Member or a student $25.00 for one year.
Print completed form and mail with payment to: Suzanne Campbell, SDONE Treas., Spearfish Hospital, 1440 N. Main Street, Spearfish, SD 57783