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Minnesota Nurse Practitioners
PO Box 16332
St. Paul, MN  55105


Membership:  Join or Renew


Please provide all the information requested and return to MNNP with payment:


Name                     _______________________________________


Address                 _______________________________________


City, State, Zip       _______________________________________


Telephone             _______________________________________
Email                      _______________________________________



Choose membership type:


______1 Year Active Membership - $65

______3 Year Active Membership - $175 (a savings of 10%)

______1 Year Student Membership - $35 (verification necessary)

______Associate Membership - $50/year


Payment Type       ______Check        ______Credit Card


Card Type              ______VISA         ______Mastercard    ______Other(                   )


                                ______________Card Number    ________Exp


Date    ______Security Code(on back of card)


                                ___________________________Name as it appears on the card.


_________________________                                                 ___________________
Signature                                                                                        Date


Please print out this page then return fully completed form to MNNP with payment enclosed by US Mail.


PROOF of membership will be emailed to you.  If no email address is given, proof will be sent to the US Mail address on record.

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