2024 New York ID/DD Nurses Association Membership Application

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Your Name* This field is required.Please enter your name
First Name
Last Name
2
Are you currently an NYSIDDDNA member? * This field is required.Please select if you are a current member of the NYSIDDDNA.
YESNO
3
NYSIDDDNA Membership NumberPlease enter your membership ID number in this field. If you don't know your number, please continue.
4
Current Status In The Nursing Field* This field is required.Please select your current nursing position.
RN, currently working
LPN, currently working
Retired Nurse
Inactive Nurse (i.e. not working, not retired)
Nursing Student
5
Nursing License NumberEnter your nursing license number in the field below
6
Do you hold CDDN?* This field is required.
YESNO
7
Select Your Zone* This field is required.Please select the zone that corresponds with the county in which your address is located.
Please Select
Please Select
Zone 1 - St. Lawrence, Franklin, Clinton & Essex
Zone 2 - Jefferson, Lewis, Oswego, Oneida, Onondaga, Madison & Herkimer
Zone 3 - Hamilton, Fulton, Washington, Warren & Saratoga
Zone 4 - Albany, Montgomery, Schoharie, Schenectady, Otsego, Delaware, Greene, Rensselaer & Columbia
Zone 5 - Sullivan, Ulster, Dutchess, Orange, Putnam, Rockland & Westchester
Zone 6 - Nassau & Suffolk
Zone 7 - New York, Richmond, King & Queens
Zone 8 - Niagara, Orleans, Genesee, Wyoming & Erie
Zone 9 & 11 - Chautauqua, Cattaraugus, Steuben, Allegany, Monroe, Wayne, Ontario, Yates, Cayuga, Seneca & Livingston
Zone 10 - Schuyler, Tompkins, Cortland, Tioga, Chenango, Broome & Chemung
Zone 12 - Members from Other States
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Where would you like to receive your mail from NYSIDDDNA?* This field is required.Please let us know if you would like to receive your mail at your work site/agency or your personal residence.
WorkHome
9
Work Site/Agency NamePlease enter your work site or agency name in the field below
10
Enter Your Preferred Mailing Address* This field is required.Please enter your preferred mailing address for communication from NYSIDDDNA. Once you start typing your address, it will start address suggestions for you.
Street Address Line 1
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
Enter Your Preferred Email Address* This field is required.Please enter your preferred email address for communication from NYSIDDDNA.
example@example.com
12
Home Phone NumberEnter your home phone number below
Please enter a valid phone number.
13
Work Phone NumberPlease enter your work phone number
Please enter a valid phone number.
14
School AttendingASSOCIATE MEMBERS ONLY need to fill out this field
15
How Would You Like To Pay Your Dues?* This field is required.You can pay by check or using by debit or credit card.
Check (agency/personal)
PayPal (Debit/Credit Card)
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Paying By Check

Member Fees
New/Renewing Members - $50
Associate Member - $30

You can mail your agency or personal check to the following address as soon as possible :

NYSIDDDNA
P.O. Box 25832
Rochester, NY 14625

Please make sure to hit "SUBMIT" to send your form information to our office and then mail your check as soon as possible.
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Choose Your Membership Level & Pay* This field is required.
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My Membership
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My Membership
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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$20
Quantity:1
Size:Small
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ORDER SUMMARY
Total costUSD
Full MembershipIf you are a new/renewing member, please select this option.
$52.30Edit
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Associate MemberIf you are a full-time nursing student or inactive nurse, please select this option.
$31.20Edit
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Total cost $0.00
Choose Your Membership Level & Pay
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