Membership Application

Membership in OMNE is open to RNs who are accountable for operational and/or management outcomes in the areas of Nursing Practice, Education and Research.  Included are RNs who wish to further develop leadership skills through education and mentorship from RNs currently in positions of leadership.  (Please check one.)

Renewal       New Member       Liaison (fee deferred)
Are you willing to mentor a new member? Yes  No  
 

Membership Fee - $150.00
Name: First, Middle Initial, Last, Credentials
Email Address

For renewing members, please change any applicable fields below.
Home Address
Home Phone
Position Title 
Hospital/Organization Name
Employer Street Address 

Employer City & Zip 

Phone
 		Fax
Referred to OMNE by:
Primary area of employment:   Hospital           Home Care         Public Health         Education         Long Term Care      
 Other: (specify)
Professional Affiliations: AONE     NLN   AACN     
 ANA-Maine     ACHE     MCHA     HCA     
 Other: (specify)
 
1.) ACTIVE PARTICIPATION ENCOURAGES ON A T LEAST ONE COMMITTEE (Check Preference)
 Bylaws      Programs      Membership      Scholarship
 Public Relations      Professional Practice

2.) Would you be interested in participating in legislative issues as necessary? Yes  No  

Please submit this completed application
Please mail dues check made payable to OMNE to:

Barbara Beal, RN, BS   
Vice President Nursing   
  Maine Coast Memorial Hospital   
50 Union Street   
Ellsworth, Maine 04605

Your name and business address will be shared with AONE database for noncommercial purposes unless you check this box.   

I am mailing the following :

Membership Fee           $150

         (Calendar year)

Scholarship Donation  $

                   (optional)

Total  $

 
 
*New members that join OMNE in the last quarter of the fiscal year, October to December, will be a member for that year and the following fiscal year, January through December.

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