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Membership Application Form

If you would rather fax or mail in this form, please print this file.
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Contact Information
First Name
Middle Initial
Last Name
Informal Name
Hospital/Office/Company Name
Preferred Mailing Address Work   Home
Work
Street Address
City
State/Province
Zip Code
Country
Phone
Internet/E-mail Address
Do you have Internet Access? Yes   No
Home
Street Address
City
State/Province
Zip Code
Country
Phone
Internet/E-mail Address
Do you have Internet Access? Yes   No


Referred by
(Members who refer other members will be entered into an annual prize drawing.)
The following information will be used for demographic purposes only. Your response is optional but appreciated
Gender Male   Female
Ethnicity
African-American Asian Caucasian Hispanic/Latino
Native American Pacific Islander Other:
Do Not Care to Respond
Date of Birth

Credentials
Education PhD   MSN   MS   BSN   BS   ADN   DIPL
Nursing RN   LPN   LVN
Certification CGRN   CGN   CGA   CGT   CGC   Other:
License Number
State
Certification Date
Other Training Technician   Nursing Assistant

Professional Profile
Professional Setting
Free Standing/Ambulatory Equipment Sales
GI Clinic GI Nursing Floor
Inpatient Only Outpatient Only
Inpatient/Outpatient Combination Physicians Office
Other
Position
Administrative/Director Clinical Specialist
Consultant Educator
Head Nurse Researcher
Staff Nurse Nurse Practitioner
Supervisor/Coordinator Sales
Technical (patient care) Technician (machine)
Other:
Memberships in Other Nursing Organizations
ANA/SNA AACN
ENA ASPAN
AORN Sigma Theta Tau
Other:
Primary Patient Population Adult   Pediatric   Both
Year I Began My Nursing Career
Year I Began My Career in GI/Endoscopy
My Current Position Is Full-time   Part-time  

Membership Options
(SGNA membership runs on a calendar year and is renewable by January 1 of the following year.) Please select the category of membership for which you are applying.
Licensed Nurse
Voting Status: Voting
Definition: Limited to Registered Nurses and Licensed Vocational/Practical Nurses involved in, or associated with, gastroenterology and/or endoscopy nursing practice
One Year Membership: $105.00  (January - December)
18 Month Membership: $165.00  (July - December)
Two Year Membership: $195.00  (January - December)
Associate
Voting Status: Voting
Definition: Limited to Assistive Personnel - technicians, technologists, assistants involved in, or associated with, gastroenterology and/or endoscopy nursing practice
One Year Membership: $105.00  (January - December)
18 Month Membership: $165.00  (July - December)
Two Year Membership: $195.00  (January - December)
Affiliate
Voting Status: Non-Voting
Definition: Includes, but is not limited to, physicians, consultants, industry representatives, educators involved in, or associated with, gastroenterology and/or endoscopy nursing practice
One Year Membership: $90.00  (January - December)
18 Month Membership: $135.00  (July - December)
Two Year Membership: $180.00  (January - December)
All voting members (licensed nurses and associates) residing in the U.S. are required to affiliate with an SGNA regional society. Regional society dues are included in the cost of licensed nurse / associate membership.

Voting Licensed Nurses and Associates: No additional payment needed, Included in Annual Dues Amount

Non-voting affiliates must select a regional society but are not required to affiliate with that regional society. Non-voting members who wish to affiliate with a regional society must pay regional society dues as indicated below:
    One Year Membership: $15.00   (January - December)
    18 Month Membership: $22.50   (July - December)
    Two Year Membership: $30.00   (January - December)

Check here if you are applying for a non-voting membership, and you would like to affiliate with a regional society.
Your State *Denotes no regional society in that state.
Possible Regional Societies
Regional Society Code
Select a numeric regional society code from above or from the list of all regions found here.
Electronic Special Interest Groups (e-SIGs) Please check here if you would like to join the SGNA e-SIGs. Note that $20 will be added to your annual membership fees. Click here for a description of e-SIGs, or on any of the individual e-SIGs listed below for a description of that particular group.

Advanced Practice LPN/LVN
Ambulatory GI Practice Manometry
Associates Nurse Endoscopist
Endoscopic Ultrasound Pediatric
ERCP Pulmonary
GI Professionals in Industry/Business Research
Hepatology University
Lab Management VA Nurses
Legislative

Payment Information
Membership Fee
Regional Society Fee
Special Interest Group Fee
Total Amount Due
Payment Method
Name as it appears on card
Card Number
Expiration Date

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