A.N.A.C - Printable Application

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

Date: ___________________ New Member: Yes / No Renewal: Yes / No Member #: ___________

PERSONAL INFORMATION

Last Name: ___________________________ Given Name(s): _________________________

Mailing Address: _______________________________________________________________

City: _____________________ Province: ______________ Posal Code: __ __ __-__ __ __

Home Telephone: ( ) __________________ Work Telephone: ( ) _________________

Fax: ( ) ___________________

E-mail: ___________________________________

Employer Name and Location: ____________________________________________________

______________________________________________________________________________

Ancestry (Aboriginal): Metis: Yes Inuit: Yes First Nations: Yes Other: ____________

Please specify to allow us to better serve our membership needs: ___________________________________

Post Secondary Education:

University: Yes BSc (Nursing): Yes Masters: Yes PhD: Yes

Other (Major/Minors): _____________________________________________________________

Hospital Diploma: Yes / No College Diploma: Yes / No

Certificate(s): ___________________________________________________________________

Language of preference: English / French

Are you a member of the CNA? Yes / No

Provincial Nurses Registration Number: Number____________ Province_________________

A.N.A.C. Use Only

Received Date _____________________ Mem # ___________________

Receipt # _____________________ Paid (cheque#) ________________

Please indicate area(s) of interest:
Perinatal / Maternal Child Health Community Health / Program Development Sexuality & Reproductive Health Chronic Diseases (e.g. Diabetes) Smoking Cessation Women's Health Traditional Healing	Substance Abuse Environmental Health Mental Health Health Promotion Family Violence Trans-Cultural Nursing Adolescent Health	FAS/FAE HIV/AIDS Disability Home Care Adolescent Health Sexual Abuse
Other: __________________________________________________________________________________

Please circle level of participation: (VERY IMPORTANT)
Committee Work in the Association Presentation A.N.A.C. conferences	Outside the Association Proposal Other conferences	Review Pertinent Paper Write papers Consulting Work (send Resumé)
______________________________________________________________________________ Please indicate topic(s) of knowledge
Add my name to your database of employment opportunities: Yes Fax: __________________

MEMBERSHIP (Our Newsletter, "The Aboriginal Nurse", is included in all levels of membership)
Regular:	$50.00	RN of Aboriginal Ancestry	(Circle method of payment enclosed)
Associate: (circle one)	$40.00	Aboriginal Health Care Personnel Non-Aboriginal RN Non-Aboriginal Health Care Personnel	Cheque # __________ Money Order # __________
Student: (circle one)	$15.00	Aboriginal Nursing Student Non-Aboriginal Student	Please fill information below
Newsletter:	$60.00	Business Subscription for Newsletter ONLY	Please fill information below

Card Number

Expiry Date

Authorization #

Signature: ____________________________________	Date: __________________________
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

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