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Your PayPal order was successful, and your payment has been sent to MANA. In order to complete your registration, please fill out the following form and submit it to the MANA membership chair.

If you forget your username and password, they are available by logging into your PayPal account and viewing your subscription details within the history log.

This form is not submitted on a secure server, however, no financial information is attached to it.

General MANA Membership Information

First Name*
Last Name*
Name on PayPal account used to pay for this membership*
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

Mothers Naturally Referral Page Information

If you paid the additional $50/year Mothers Naturally Referral Fee, please fill out the information below as you would like it to appear when your name is shown during a search on the Mothers Naturally referral web page.

If you chose not to pay the additional Mothers Naturally referral fee, please scroll down here to fill in additional information for your MANA membership.

Name
Credential(s) to appear
Street Address
City
State/Province
Postal Code
Country
Office or Work Phone Number
E-mail
Your web page URL

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

Comments:

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