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DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Work PhoneCNephC* Yes No CNA* Yes No Ontario applicants only: Member RNAO* Yes No N/A Manitoba applicants only: Member ARNM* Yes No N/A Quebec applicants only: Are you a member of ReinQ? Yes No N/A Professional Status*Registered NurseNurse PractitionerRegistered Practical Nurse/ Registered Nursing Assistant/ Licensed Practical NurseTechnicianTechnologistOther (Please specify below)Professional Status Other Number Years Nephrology Area of responsibility*Direct Patient CareAdministrationTechnicalTeachingResearchOther (please specify)Area of responsibility Other Work environment*Acute CareSelf-Care UnitIndependent Health CarePrivate SectorLevel of Education NursingDiplomaBaccalaureateMastersDoctorateN/ALevel of Education nonNursingSpeciality CertificateBaccalaureateMastersDoctorateN/APrimary Area of Practice*PediatricAdultCombined Adults/ PediatricsOther (Please Specify Below)Area Practice Other: Specific area of practice (select all that apply)* Select All Full Care Hemo (In centre) Self Care Hemo Home/Independent Hemo In-Patient Nephrology Nephrology Outpatient Clinics In-Patient Peritoneal Dialysis In-Patient Transplantation Home/Independent PD Out-Patient Transplantation Clinical Educator Academic Educator Corporate Educator Vascular/Body Access Nurse Navigator Research Administration Corporate Sales Consent Name Address*YesNoConsent Name Email*YesNoChoose Membership* Associate Member - One Year Associate Member - Two Year Nurse Member - One Year Nurse Member - Two Year Technologist Member – One Year Technologist Member – Two Year Student Member – One Year Technologist Member – One Year - Limited Time I agree to attend at least one focus group meeting.* Yes, I agree In order to better serve our technologist members, we are offering a limited time membership for $40.00. In order to take advantage of this price, you must agree to attend at least one focus group meeting to determine what membership benefits would be of interest.Discount code If you were provided a discount code enter it hereSubtotal $ 0.00 CAD Discount $ 0.00 CAD GST $ 0.00 CAD HST $ 0.00 CAD HST $ 0.00 CAD Provincial Tax $ 0.00 CAD Provincial Tax $ 0.00 CAD Provincial Tax $ 0.00 CAD QST $ 0.00 CAD Total $ 0.00 CAD Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name Hiddenregname HiddenUntitled HiddenHighestUserID HiddenOldUserId Untitled
