Aboriginal Nurses Association of Canada - Membership Application and Renewal Form

Membership Application and Renewal Form
2002/2003
56 Sparks Street, Suite 502
Ottawa, Ontario K1P 5A9
Telephone: (613) 724-4677 Fax: (613) 724-4718
E-mail: info@anac.on.ca

Click for a printable form to mail or fax - Visa and Mastercard included on form.

Date: New Member: Yes No Renewal: Yes No

Member #

PERSONAL INFORMATION

Last Name:
Given Name (s):
Mailing Address:

City:		Province:
Postal Code:		Phone (home):
Phone (work):		Fax:
E-Mail:
Employer Name and Location:
Ancestry: Metis Inuit First Nations Other
Please specify to allow us to better serve our membership needs:


BACKGROUND INFORMATION
	Post Secondary Education: University BSc (Nursing) Masters PhD Other:
	Hospital Diploma?	Yes No
	College Diploma?	Yes No
	Certificates:
	Language of Preference:	English French
	A Member of the CNA?	Yes No
	Provincial Nurses Registration Number:		Province:

A.N.A.C. Use Only

Received Date _____________________ Mem # ___________________

Receipt # _____________________ Paid (cheque#) ________________

PLEASE INDICATE YOUR AREA(S) OF INTEREST
	Perinatal/Maternal Child Health	Family Violence
	Community Health/Program Development	HIV/AIDS
	Chronic Diseases (i.e. Diabetes)	Sexual Abuse
	Substance Abuse	Mental Health
	Sexuality/Reproductive Health	Smoking Cessation
	Home Care	Traditional Healing
	Environmental Health	FAS/FAE
	Health Promotion	Disability
	Trans-Cultural Nursing	Women's Health
	Adolescent Health
	Other:


	PLEASE INDICATE YOUR DESIRED LEVEL OF PARTICIPATION: (Very Important)
		Committee Work within the Association		Presentations
	Committee Work outside the Association		Proposals
	Review Pertinent Paper		Write papers
	A.N.A.C. Conferences		Other Conferences
	Consulting Work (send R�sum�)
Please indicate topic(s) of knowledge:
Add my name to your database of employment opportunities: Yes Fax:

The National Office is often approached to release current mailing lists for the purpose of communicating health-related information and notices. Please indicate your approval:
Yes No

MEMBERSHIP (Our Newsletter, "The Aboriginal Nurse", is included in all levels of membership)
	Regular	RN of Aboriginal Ancestry	$50.00
	Associate		$40.00
	Student		$15.00
	Newsletter	(Business Subscription for Newsletter Only)	$60.00

Method of Payment: Cheque # Money Order # Visa Master Card Credit Card Number: Expiry Date: Authorization #
NOTE: Visa and MasterCard Registration is provided on the printable form. We advise that you use this method and mail in your registration, however you may use the area above if you choose. Your Website membership application will be held and processed only when we receive your payment. If not using Visa or MasterCard, be sure to make a ' web registration ' reference on your cheque or money order and make it payable to: "Aboriginal Nurses Association of Canada" Mail to: Membership Registration Aboriginal Nurses Association of Canada 56 Sparks Street, Suite 502 Ottawa, Ontario K1P 5A9

If you prefer, you can print this form and mail it with your payment or use the printable form

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