• Hawaii Nurses' Association Membership Application

  • Contact Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Primary Employment

  • Primary Employer Date of Hire*
     / /
  • Primary Employer FTE*
  • Dues Rate

  • Secondary Employment

    Please fill in only if you have secondary employment elsewhere
  • Secondary Employer FTE

  • Union Membership Fees

    Informational only, nothing to fill out on this page

  • Initiation Fee

    • New Members Only / Amount = $100.00
    • Paid via check or credit card directly by member.
    • A bill will be mailed to you for this charge.

  • METHOD OF PAYMENT FOR MEMBERSHIP DUES

  • Payroll Deduction

    • Automatic deduction of your dues from your paycheck.
    • You must complete and submit the Exhibit B or other authorization form.
    • Please see the payroll deduction intstructions contained in your new hire packet.
    • Please allow a minimum of 1-2 pay periods for payroll deductions to start.

     

    Direct Payment

    • You will receive a monthly billing statement via mail.
    • $2.00 processing fee will apply.
    • Must pay HNA directyly via check or online card payment.
    • Card payments accepted at hawaiinurses.org/payonline
    • A 3% surcharge for credit cards will apply, no fee for debit cards.
  • Payment Method*

  • Thank you for choosing to sign up for payroll deduction. After signing and submitting this form on the next page, you'll be redirected to also complete the payroll deduction authorization form.

  • Signature

  • I, the undersigned, do hereby apply for membership in the Hawaii Nurses' Association and agree to be bound by and to follow the Constitution and By-Laws of the Union and I further agree to be bound by and to follow the Constitution and By-Laws of the International Union.

  • Date
     / /

  • Since you elected to sign up for payroll deduction on the previous page, you'll be redirected to also complete the payroll deduction authorization form after submitting this form.

  • Should be Empty: