Membership Form
Region IV Chapter 9 of the American College of Nurse-Midwives


PLEASE PRINT LEGIBLY AND INCLUDE AREA CODES ON YOUR PHONE NUMBERS

Name:____________________________________________________________________

Address:__________________________________________________________________

City, State, Zip:_____________________________________________________________

Home Phone: (___)__________________   Business Phone: (___)_____________________

Email address: _____________________________________________________________

Membership Category:
 q$100: CNM Dues/Legislative Support             q$75: CNM Dues 

q$50: CNM’s in a CNM Owned Practice          q$35: SNM Dues

q$30: Friend of VA ACNM                              q$30: Associate Member

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Check should be made payable to "Virginia ACNM"    Please send your check or money order to:

Karen R. Nguyen, CNM (Chapter Treasurer)
260 Rubinette Way
Winchester VA 22602-2521


CAN YOU HELP WITH A COMMITTEE? (Please Circle)

Nominating - Legislative - Continuing Ed - Peer Review - Fund Raising - Archives - Publicity

Call/write/e-mail your legislators?           Yes            No

Can you lobby in Richmond?                  Yes            No

Meet with your legislators?                     Yes           No

If you can’t participate, your check is enough.