MW MSD Individual Activity

Organization Name*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Activity Title*

Activity Date*

Contact Name*

First NameLast Name

Contact Title*

Preferred Phone*

Area CodePhone Number

Preferred E-mail*

Previous Approval: Has your organization received approval from another state nurses association or another ANCC Accredited Aprrover Unit in the past 12 months?*

YesNo

Which nurses association approved your organization?*

Select a payment type*

Credit CardCheck

Please make check payable to:

MW MSD

* Application review fees must be paid prior to approval being issued.

0.5-5 contact hours

$150

5.1-11 contact hours

$250

11.1-17 contact hours

$350

17.1-23 contact hours

$450

23.1 or more contact hours

$450 plus ten dollar fee per contact hour. Enter contact hours below.

Number of Contact Hours*

$10 Per Contact Hour

Total for 23.1 or more contact hours

Total Amount

Total You Pay

USDDescription

Payment Method
Credit	Express
Credit	What is PayPal?

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

TEST: Individual Activity Application Payment Form