MEMBERSHIP APPLICATION
* Indicates required field
Name
*
First Name
Last Name
Email
*
example@example.com
Employer Name
*
Employer City
Mobile Number
*
Format: (000) 000-0000.
AVA Member
Yes
No
Not Sure
VA-BC Certified
Yes
No
Professional License Number
*
Profession
*
Registered Nurse
Physician
Respiratory Therapy
Physician Assistant
Advanced Practice Nurse
Clinical Educator
Industry Partner
Manager/Administrator
Other
Membership Options
1 year = $40 (in-person meetings/ Virtual) *BEST OPTION*
Non-Member In-Person meetings/ Virtual = $15/meeting
Student = $5/meeting
Groups of 5 or more= $35 per person/year
Employer Type
*
Hospital
Infusion Clinic
Long term Care/Skilled Nursing Facility
Home Health/ Infusion
Dialysis Center
Industry
Other
Payment Options:
Pay online with Credit Card with Paypal at PayPal.Me/WESTEXVAN
Venmo at WESTEX VAN @WESTEXVAN
Mail check to 1616 S. Kentucky Suite C-260. Amarillo, TX 79102
Click the Submit button below and you will be directed to PayPal
Submit
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