Become a Member

Name*

First Last

Salutation

Were you referred by a CANNT member? If so, please enter their name:

First Last

Please list your professional designations*

Address*

Street Address Address Line 2 City ZIP / Postal Code Country

Province/States*

Email*

Phone*

Company*

Work Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone

CNephC*

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*

Professional Status Other

Number Years Nephrology

Area of responsibility*

Area of responsibility Other

Work environment*

Level of Education Nursing

Level of Education nonNursing

Primary Area of Practice*

Area Practice Other:

Specific area of practice (select all that apply)*

Consent Name Address*

Consent Name Email*

Choose Membership*

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 here

Subtotal

$ 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 Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

regname

Untitled

HighestUserID

OldUserId

Untitled