MEMBERSHIP APPLICATION

MEMBERSHIP APPLICATION

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Name*

First NameLast Name
Email*
example@example.com
Employer Name*
Mobile Number*
VA-BC Certified

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AVA Member

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AVA Member Number
Please enter your AVA member #
Professional License Number*
Employer Type*

HospitalLong Term Care/Skilled NursingInfusion ClinicHome Health/ InfusionDialysis CenterIndustryOther
Profession*

Registered NursePhysicianManager/AdministratorRespiratory TherapyPhysician AssistantAdvanced Practice NurseClinical EducatorIndustry PartnerPatientOther
THANK YOU FOR JOINING US!

Membership dues are $40 annually

When you click SUBMIT you will be redirected to PayPal to complete the application process and pay your membership dues.

You do not need a PayPal account to process your payment. You may simply click on CHECK OUT to process your credit /debit card payment.
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