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CANNT Membership.

First Name _________________________

Last Name _________________________

Home Address ______________________

City________________________________

Province______________Postal Code_____________

Telephone (H) (______)______-___________

(W) (______)______-___________

Email _________________________

Employer _____________________

Employer Address ______________

City___________________________

Province____________ Postal Code __________

Do you consent to the use of your name and address on mailing lists that CANNT has considered pertinent and appropriate?

[] Yes [] No

Do you consent to the use of your email for all correspondence with CANNT?

[] Yes [] No

[] New Member or [] Renewal

CANNT # (if renewal): _____________________

Membership Fee (HST #100759869)

Membership fee is tax deductible.

[] One Year: $75.00 + HST/GST

[] Two Years: $140.00 + HST/GST

[] Student Rate: $37.50 + HST/GST*

*Proof of full-time enrolment must accompany application

AB/BC/SK/MB/NT/NU/QC/YT: 5% GST; ON/NL/NB: 13% HST; PEI: 14% HST; NS: 15% HST

I enclose $___________ made payable to Canadian Association of Nephrology Nurses and Technologists.

Method of payment:

[] Cheque [] Money order [] Visa [] Mastercard

Cardholder Name: _______________________

Credit Card Number: ____________________

Expiry Date: _________________ 3-digit CVV code:________

Signature:______________________________________________

Return to CANNTT Mailing Address:

CANNT, 4 Cataraqui Street, Suite 310 Kingston, ON K7K 1Z7

[] I have attained CNeph(C)/cdt designation

[] I am a member of CNA

Ontario applicants only

Do you belong to RNAO?

[] Yes [] No

Professional Status

[] Registered Nurse

[] Registered Practical Nurse/Registered Nursing Assistant/Licensed Practical Nurse

[] Technician

[] Technologist

[] Other (Specify) ______________________

Number of years in nephrology____________

Area of responsibility

[] Direct Patient Care

[] Administration

[] Technical

[] Teaching

[] Research

[] Other (Specify)

Work environment

[] Acute Care

[] Self-Care Unit

[] Independent Health Care

[] Private Sector

Highest level of education

Nursing

[] Diploma

[] Baccalaureate

[] Master's

[] Doctorate

Non-Nursing

[] Diploma

[] Baccalaureate

[] Master's

[] Doctorate

I am at present studying toward

Nursing

[] Specialty Certificate

[] Baccalaureate

[] Master's

[] Doctorate

Non-Nursing

[] Specialty Certificate

[] Baccalaureate

[] Master's

[] Doctorate

Primary area of practice

Choose one

[] Adults

[] Combined Adult/Pediatrics

[] Pediatrics

[] Other

Select all that apply

[] Full-Care Hemo

[] Self-Care Hemo

[] Home/Independent Hemo

[] In-Patient Nephrology

[] In-Patient Peritoneal Dialysis

[] In-Patient Transplantation

[] Home/Independent PD

[] Out-Patient Transplantation

[] Clinical Educator

[] Academic Educator

[] Corporate Education

[] Vascular/Body Access

[] Nurse Navigator

[] Research

[] Administration

[] Corporate Sales
COPYRIGHT 2018 Canadian Association of Nephrology Nurses & Technologists
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Publication:CANNT Journal
Date:Apr 1, 2018
Words:318
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