Retired Membership

One-Time Credit Card Payment

Be sure to enter your BILLING address.

TERMS:
– $40 / year payable via Credit Card.
– A Credit Card payment must be submitted each year.

First Name:* First Name Required

Last Name:* Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Middle Initial: Middle Initial is not valid

Credential: Credential is not valid

Parish Name: Parish Name is not valid

Diocese: Diocese is not valid

Employer: Employer is not valid

Position: Position is not valid

Phone:* Phone is Required

Date Of Birth (retired members must be 62 yrs or older):* Date Of Birth (retired members must be 62 yrs or older) is Required

Name of Council: Name of Council is not valid

Referred By: Referred By is not valid

As a benefit of your membership, your contact information will be shared with the local Regional Director and Nurses Council. If you prefer NOT to have your information shared please indicate so below:: As a benefit of your membership, your contact information will be shared with the local Regional Director and Nurses Council. If you prefer NOT to have your information shared please indicate so below: is not valid

Yes No

Username:* Invalid Username

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Password Confirmation Doesn't Match

No val Please fix the errors above