If you would like to join MANA, type your information on the following form, print and mail it to the address below with payment. You will not be submitting this form via the internet.

First Name*
Last Name*
Membership Number
     (If you have one)
Street Address*
City*
State/Province*
Postal Code*
Country*
Home Phone Number
Work Phone Number
Fax number
E-mail
*Required information

I am a (check all that apply):
 CPM  Nurse  Apprentice
 CNM  Doctor  Childbirth Educator
 Midwife  Student  Other

As a Midwife I am:

Licensed

 Yes No
 Certified Yes No
In What State or Province? 

Please include me in the Midwife of Color Section  in addition to my geographical region. Yes No

I am interested in volunteering for the following committee work: 

My Name and Address
Can Be Released For:
Persons seeking a midwife Yes No
Persons doing research Yes No
Conferences and announcements Yes No
Midwifery related products Yes No

Choose One Type of Membership (in U.S. funds)

Qualifications
Voting/non-voting
Family Income
Term
Cost
  
Midwife Voting over $50,000 1 year $125
Midwife Voting $20-50,000 1 year $85
Midwife Voting under $20,000 1 year $60
Midwife Voting over $50,000 2 years $225
Midwife Voting $20-50,000 2 years $153
Midwife Voting under $20,000 2 years $108
Midwife Voting over $50,000 3 years $338
Midwife Voting $20-50,000 3 years $230
Midwife Voting under $20,000 3 years $162
Student/Apprentice Non-voting over $20,000 1 year $55
Student/Apprentice Non-voting under $20,000 1 year $40
Student/Apprentice Non-voting over $20,000 2 years $99
Student/Apprentice Non-voting under $20,000 2 years $72
Student/Apprentice Non-voting over $20,000 3 years $149
Student/Apprentice Non-voting under $20,000 3 years $108
Supporting Non-voting n/a 1 year $40
Supporting Non-voting n/a 2 years $72
Supporting Non-voting n/a 3 years $108
If you have national certification or are licensed or certified by a state government and wish to support the ICM dues for MANA, add $10 1 year $10

If you are interested in a group membership, contact Nina McIndoe for more information.

Payment Information

I have enclosed the following amount $ (in U.S. funds) in either:

 Check made out to MANA
 Money Order made out to MANA
 Credit Card payment with information below:

Exact Name on Credit Card:__________________________________________________

Credit Card Number (Master Card or Visa only):___________________________________

Credit Card Expiration Date: ___________________________

Authorizing Signature: _____________________________________________________

If you would like to join the MANA "Members Only" section on the web, please be sure you have filled in an e-mail address above and click here . We will e-mail your username and password in a few days after receipt of this form and payment.

Print out this completed form and mail it along with your payment to —
Nina McIndoe
MANA Membership Chair
2471 Waterfall Lane
Columbus, OH  43209

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