Annual Dues Form

Samaritan Hospital School of Nursing Alumni Association, Inc
Annual Dues Payment Voucher

Annual dues ($25) are payable by January 1 for the current membership year and should be sent to:
Samaritan Hospital School of Nursing Alumni Inc.
Attn: Treasurer
2215 Burdett Avenue
Troy, New York 12180

Please print payment information:

Name:
First _________________ Maiden _______________ Last __________________________

Year of Graduation __________

Address ________________________________________ _______________________________________________
_______________________________________________

Is this a new address? No _________ Yes_________

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