Monthly Payment via ACH - Non-Collective Bargaining Membership Application

2017 Dues Rates

Membership Application - Monthly EFT Option via ACH 2017

Non-Collective Bargaining Membership Application for Monthly EFT Payors via ACH

Membership includes Ohio Nurses Association, American Nurses Association and District Nurses Association.
Name*
First Last
Degrees*
Last 4 Digits of SSN*
Address*
Street Address City State ZIP Code
Phone*
Email*
Enter Email Confirm Email
Employer*
US Citizen?*
- Yes
- No
Date of Birth*
Month
Day
Year
RN License Number*
License State*
Basic School of Nursing*
Month and Year of Graduation from Basic Nursing Program*
ANA Promo Code (if applicable)
The county in which you live or work determines your District. ONA Bylaws state that you must live or work in your District. If you live in one county and work in another, it is your choice as to which district you belong.
The dollar amounts represent the amount that will be deducted from your checking account via ACH on a monthly basis.
Select your District:*
- 03 District Three: Columbiana, Mahoning, Trumbull
- 10 District Ten: Butler, Champaign, Clark, Darke, Greene, Mercer, Miami, Montgomery, Preble, Shelby
- 17 East Central: Harrison, Jefferson, Tuscarawas
- 07 Erie-Huron: Erie, Huron
- 16 Greater Cleveland: Cuyahoga, Geauga
- 18 Knox-Licking: Knox, Licking
- 19 Lake County: Lake
- 12 Mid-Ohio: Delaware, Fairfield, Fayette, Franklin, Logan, Madison, Pickaway, Union
- 05 Mohican: Ashland, Crawford, Marion, Morrow, Richland
- 28 Muskingum Valley: Coshocton, Guernsey, Morgan, Muskingum, Noble, Perry
- 35 Northwest Ohio: Defiance, Fulton, Henry, Lucas, Ottawa, Sandusky, Seneca, Williams, Wood
- 15 Southern Ohio: Adams, Athens, Gallia, Highland, Hocking, Jackson, Lawrence, Meigs, Pike, Ross, Scioto, Vinton
- 08 Southwestern Ohio: Brown, Clermont, Clinton, Hamilton, Warren
- 33 Stark Carroll: Carroll, Stark
- 34 Summit and Portage: Portage, Summit
- 13 West Central Ohio: Allen, Auglaize, Hancock, Hardin, Paulding, Putnam, Van Wert, Wyandot
- 37 At Large District: Ashtabula, Belmont, Eastern Valley, Holmes, Lorain, Medina, Monroe, Washington, Wayne and members who do not live or work in the state of Ohio.
Non-collective bargaining membership assessments and dues include the National, State and District fees. One dollar ($1.00) per month of your dues goes to an account set up to support ONA’s political efforts. You may choose at anytime to opt out of this dues designation. Opting out does not reduce the dues amount. If you are interested in opting out, please contact the Director of Health Policy at 614-237-5414. ONA dues are not deductible as a charitable contribution for federal income tax, but can be partially deductible as a business expense. A percent of the dues not deductible is calculated each year based on the amount spent lobbying. When preparing your taxes, contact ONA for the percentage that is deductible in the year you make this payment. ONA dues are nonrefundable. Your category from the list below determines your dues amount.
Membership Categories (choose one)*
- Employed Full or Part Time
- Not employed
- First year of membership for new graduates from basic nursing education program (second year of membership, new grads pay the 75% rate)
- Full-time Student (must provide documentation)
- 62 years of age or older who are not earning more than the social security system allows at age 62
- 62 or over and not employed
- Totally Disabled
Mid-Ohio District (12) Full or Part Time (Full Rate)
Price:
Mid-Ohio District (12) Not Employed (50% Reduced Rate)
Price:
Mid-Ohio District (12) First year of membership for new graduates from basic nursing education program
Price:
Mid-Ohio District (12) Full-time Student (50% Reduced Rate)
Price:
Mid-Ohio District (12) 62+ not earning more than Social Security allows at age 62 (50% Reduced Rate)
Price:
Mid-Ohio District (12) 62+ Not Employed (25% Special Rate)
Price:
Mid-Ohio District Totally Disabled (25% Special Rate)
Price:
District Three (03) Full or Part Time (Full Rate)
Price:
District Ten (10) Full or Part Time (Full Rate)
Price:
East Central (17) Full or Part Time (Full Rate)
Price:
Erie Huron (07) Full or Part Time (Full Rate)
Price:
Greater Cleveland (16) Full or Part Time (Full Rate)
Price:
Knox-Licking (18) Full or Part Time (Full Rate)
Price:
Lake County (19) Full or Part Time (Full Rate)
Price:
Mohican (05) Full or Part Time (Full Rate)
Price:
Muskingum Valley (28) Full or Part Time (Full Rate)
Price:
Northwest Ohio (35) Full or Part Time (Full Rate)
Price:
Southern Ohio (15) Full or Part Time (Full Rate)
Price:
Southwestern Ohio (08) Full or Part Time (Full Rate)
Price:
Stark Carroll (33) Full or Part Time (Full Rate)
Price:
Summit & Portage (34) Full or Part Time (Full Rate)
Price:
West Central (13) Full or Part Time (Full Rate)
Price:
At Large District (37) Full or Part Time (Full Rate)
Price:
District Three (03) Not Employed (50% Reduced Rate)
Price:
District Ten (10) Not Employed (50% Reduced Rate)
Price:
East Central (17) Not Employed (50% Reduced Rate)
Price:
East Central (17) First year of membership for new graduates from basic nursing education program
Price:
East Central (17) Full-time Student (50% Reduced Rate)
Price:
East Central (17) 62+ not earning more than Social Security allows at 62 (50% Reduced Rate)
Price:
Erie Huron (07) Not Employed (50% Reduced Rate)
Price:
Erie Huron (07) First year of membership for new graduates from basic nursing education program
Price:
Erie Huron (07) Full-time Student (50% Reduced Rate)
Price:
Erie Huron (07) 62+ not earning more than Social Security allows at 62 (50% Reduced Rate)
Price:
Greater Cleveland (16) Not Employed (50% Reduced Rate)
Price:
Greater Cleveland (16) First year of membership for new graduates from basic nursing education program
Price:
Greater Cleveland (16) Full-time Student (50% Reduced Rate)
Price:
Greater Cleveland (16) 62+ not earning more than Social Security allows at 62 (50% Reduced Rate)
Price:
Knox-Licking (18) Not Employed (50% Reduced Rate)
Price:
Knox-Licking (18) First year of membership for new graduates from basic nursing education program
Price:
Knox-Licking (18) Full-time Student (50% Reduced Rate)
Price:
Knox-Licking (18) 62+not earning more than Social Security allows at 62 (50% Reduced Rate)
Price:
Lake County (19) Not Employed (50% Reduced Rate)
Price:
Lake County (19) First year of membership for new graduates from basic nursing education program
Price:
Lake County (19) Full-time Student (50% Reduced Rate)
Price:
Lake County (19) 62+ not earning more than Social Security allows at age 62 Monthly Electronic Dues Payment Plan (50% Reduced Rate)
Price:
Lorain County (24) First year of membership for new graduates from basic nursing education program
Price:
Lorain County (24) Full-time Student (50% Reduced Rate)
Price:
Mohican (05) Not Employed (50% Reduced Rate)
Price:
Mohican (05) First year of membership for new graduates from basic nursing education program
Price:
Mohican (05) Full-time Student (50% Reduced Rate)
Price:
Mohican (05) 62+ not earning more than Social Security allows at age 62 Monthly Electronic Dues Payment Plan (50% Reduced Rate)
Price:
Muskingum Valley (28) Not Employed (50% Reduced Rate)
Price:
Muskingum Valley (28) First year of membership for new graduates from basic nursing education program
Price:
Muskingum Valley (28) Full-time Student (50% Reduced Rate)
Price:
Muskingum Valley (28) 62+ not earning more than Social Security allows at age 62 Monthly Electronic Dues Payment Plan (50% Reduced Rate)
Price:
Northwest Ohio (35) Not Employed Monthly Electronic Dues Payment Plan (50% Reduced Rate)
Price:
Northwest Ohio (35) First year of membership for new graduates from basic nursing education program
Price:
Northwest Ohio (35) Full-time Student (50% Reduced Rate)
Price:
Northwest Ohio (35) 62+ not earning more than Social Security allows at age 62 Monthly Electronic Dues Payment Plan (50% Reduced Rate)
Price:
Southern Ohio (15) Not Employed (50% Reduced Rate)
Price:
Southern Ohio (15) First year of membership for new graduates from basic nursing education program
Price:
Southern Ohio (15) Full-time Student (50% Reduced Rate)
Price:
Southern Ohio (15) 62+ not earning more than Social Security allows at age 62 Monthly Electronic Dues Payment Plan (50% Reduced Rate)
Price:
Southwestern Ohio (08) Not Employed (50% Reduced Rate)
Price:
Southwestern Ohio (08) First year of membership for new graduates from basic nursing education program
Price:
Southwestern Ohio (08) Full-time Student (50% Reduced Rate)
Price:
Southwestern Ohio (08) 62+ not earning more than Social Security allows at age 62 Monthly Electronic Dues Payment Plan (50% Reduced Rate)
Price:
Stark Carroll (33) Not Employed (50% Reduced Rate)
Price:
Stark Carroll (33) First year of membership for new graduates from basic nursing education program
Price:
Stark Carroll (33) Full-time Student (50% Reduced Rate)
Price:
Stark Carroll (33) 62+ not earning more than Social Security allows at age 62 Monthly Electronic Dues Payment Plan (50% Reduced Rate)
Price:
Summit & Portage (34) Not Employed (50% Reduced Rate)
Price:
Summit & Portage (34) First year of membership for new graduates from basic nursing education program
Price:
Summit & Portage (34) Full-time Student (50% Reduced Rate)
Price:
Summit & Portage (34) 62+ not earning more than Social Security allows at age 62 Monthly Electronic Dues Payment Plan (50% Reduced Rate)
Price:
West Central (13) Not Employed (50% Reduced Rate)
Price:
West Central (13) First year of membership for new graduates from basic nursing education program
Price:
West Central (13) Full-time Student (50% Reduced Rate)
Price:
West Central (13) 62+ not earning more than Social Security allows at age 62 Monthly Electronic Dues Payment Plan (50% Reduced Rate)
Price:
At Large District (37) Not Employed (50% Reduced Rate)
Price:
At Large District (37) First year of membership for new graduates from basic nursing education program
Price:
At Large District (37) Full-time Student (50% Reduced Rate)
Price:
At Large District (37) 62+ not earning more than Social Security allows at age 62 Monthly Electronic Dues Payment Plan (50% Reduced Rate)
Price:
District Three (03) First year of membership for new graduates from basic nursing education program
Price:
District Ten (10) First year of membership for new graduates from basic nursing education program
Price:
District Three (03) Full-time Student (50% Reduced Rate)
Price:
District Ten (10) Full-time Student (50% Reduced Rate)
Price:
District Three (03) 62+ not earning more than Social Security allows at age 62 Monthly Electronic Dues Payment Plan (50% Reduced Rate)
Price:
District Ten (10) 62+ not earning more than Social Security allows at age 62 Monthly Electronic Dues Payment Plan (50% Reduced Rate)
Price:
District Three (03) 62+ Not Employed (25% Special Rate)
Price:
District Ten (10) 62+ Not Employed (25% Special Rate)
Price:
East Central (17) 62+ Not Employed (25% Special Rate)
Price:
East Central (17) Totally Disabled (25% Special Rate)
Price:
Erie Huron (07) 62+ Not Employed (25% Special Rate)
Price:
Erie Huron (07) Totally Disabled (25% Special Rate)
Price:
Greater Cleveland (16) 62+ Not Employed (25% Special Rate)
Price:
Greater Cleveland (16) Totally Disabled (25% Special Rate)
Price:
Knox-Licking (18) 62+ Not Employed (25% Special Rate)
Price:
Knox-Licking (18) Totally Disabled (25% Special Rate)
Price:
Lake County (19) 62+ Not Employed (25% Special Rate)
Price:
Lake County (19) Totally Disabled (25% Special Rate)
Price:
Mohican (05) 62+ Not Employed (25% Special Rate)
Price:
Mohican (05) Totally Disabled (25% Special Rate)
Price:
Muskingum Valley (28) 62+ Not Employed (25% Special Rate)
Price:
Muskingum Valley (28) Totally Disabled (25% Special Rate)
Price:
Northwest Ohio (35) 62+ Not Employed (25% Special Rate)
Price:
Northwest Ohio (35) Totally Disabled (25% Special Rate)
Price:
Southern Ohio (15) 62+ Not Employed (25% Special Rate)
Price:
Southern Ohio (15) Totally Disabled (25% Special Rate)
Price:
Southwestern Ohio (08) 62+ Not Employed (25% Special Rate)
Price:
Southwestern Ohio (08) Totally Disabled (25% Special Rate)
Price:
Stark Carroll (33) 62+ Not Employed (25% Special Rate)
Price:
Stark Carroll (33) Totally Disabled (25% Special Rate)
Price:
Summit & Portage (34) 62+ Not Employed (25% Special Rate)
Price:
Summit & Portage (34) Totally Disabled (25% Special Rate)
Price:
West Central (13)62+ Not Employed (25% Special Rate)
Price:
West Central (13) Totally Disabled (25% Special Rate)
Price:
At Large District (37) 62+ Not Employed (25% Special Rate)
Price:
At Large District (37) Totally Disabled (25% Special Rate)
Price:
District Three (03) Totally Disabled (25% Special Rate)
Price:
District Ten (10) Totally Disabled (25% Special Rate)
Price:
Total
$0.00
Monthly payments are automatically deducted via ACH from your checking or savings account. By signing up for this payment plan, you authorize ONA to withdraw monthly dues payments via ACH on or after the 15th day of each month from your checking or savings account. The amount deducted includes a 33 cent service fee. ONA is authorized to change the amount withdrawn by giving you (30) days notice. You may cancel this authorization upon receipt of ONA of written notification of termination twenty (20) days prior to the deduction date designated above. ONA will charge a $15.00 fee for any returned ACH transactions.
Name of Bank*
Bank Account Number*
Routing Number*
Account Type*
- Checking
- Savings
I authorize the Ohio Nurses Association to withdraw monthly dues payments via ACH on or after the 15th of each month from the account specified above.*

If you agree, type your full name in this field.
It is recommended on your behalf to print and keep this for your records.
Phone
This field is for validation purposes and should be left unchanged.