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NEPALI NURSES ASSOCIATION CANADA (NNAC)
MEMBERSHIP REGISTRATION FORM
1.Personal Information
Full Legal Name: __________________________________________
2.Professional Status (check one):
☐ RN (Registered Nurse)
☐ RPN (Registered Practical Nurse)/LPN (Licensed Practical Nurse)
☐ NP (Nurse Practitioner)
☐ Nursing Student
☐ Other: __________________________
- Contact Information
City: __________________ Province/State: _____________
Phone Number: ____________________________________
Email Address: _____________________________________ - Membership Details
Membership Type (check one):
☐ Life Member – $100 (one-time payment)
☐ General Membership – $25 per term (2 years) - Payment Information
Payment Method: e-Transfer
Please send your membership fee via e-transfer to:nnacanada2022@gmail.com
Amount Sent: $_________________ Date Sent: ____________________
Please include your full name in the e-transfer message for identification.
- Agreement & consent
I hereby apply for membership with NNAC and agree to abide by its rules, policies, and code of conduct.
Signature/Initials: __________________________
Date: __________________________
Information
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