Become a Member – CANNT-ACITN

Name*

First Last

Salutation

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*

Subtotal

$ 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

MemberID

OldUserId