2012/2013ONSA MEMBERSHIP FORM

(May 1, 2012 – April 30, 2013)

Personal Information

PLEASE PRINT CLEARLY PLEASE PROVIDE ALL INFORMATION REQUESTED

Date: _____________________________________ (mm/dd/yyyy)

Name: ________________________________________________________________________________________________________________

Home Address: ________________________________________________________________________________________________________

City: ________________________________________________ Postal Code: ____________________________________________________

Home Phone: (________) _______________________________ Home Fax: (________) ____________________________________________

Work Phone: (________) _______________________________ Work Fax: (________) ____________________________________________

Primary Email _______________________________________ Secondary Email: (if applicable)_ __________________________________

Employer:_____________________________________________________________________________________________________________

CRNBC# ________________________________________________________________ (Required field – confidentiality maintained)

COHN(C) certificate# _____________________________________________________ (Required for COHNA)

Yes No I consent to be included on the membership list distributed to ONSA members.

Membership fee. Check () one:

$60.00 Regular Members (Must have CRNBC registration)

$40.00 Associate Members (No CRNBC registration)

Make cheque payable to: Occupational Nurses’ Specialty Association or ONSA

Mail cheque and form to:

Doreen Yanick – Specialist OHNCatalyst Paper201-65th Front street Nanaimo, BCV9R 5H9

1. Check () One:

Full Member (Current CRNBC#)

Associate Member (No CRNBC#)

2. Check () One:

I am a new Member

I am a renewing member

I am retired (No longer practicing)

(Information on the membership list falls under the provisions of the Freedom of Information of Privacy Act)

Occupational Nurses’ Specialty Association

of British Columbia

ONSA