Membership form 2021

NNPBC Membership Form - 2021

Please fill the membership form below.

Contact Information
Name*
First name (official) Preferred name (if different from official) Last name
Home Address*
Street Address Address Line 2 City Province / State Postal Code Country
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Email address
Home Phone*
Mobile Phone
Designation*
Current nursing designation or past designation if retired.
Retired
- I am currently retired from nursing
Nursing Registration Number*
Primary Employer
Years of Practice*
Please enter a number from 0 to 100.
Nursing sub-specialty
Do you identify yourself as an Aboriginal person, that is First Nations, Inuit or Métis?
- Yes
- No
- Prefer not to answer
If you identify as an Aboriginal person are you:
- First Nations
- Inuit
- Métis
School Information
School
Program
Graduation Year
Student ID #
Professor/Teacher Reference Name
Communication Preferences
Allow Councillor
- I give NNPBC consent to share my contact details with my local NNPBC Councillor for communications purposes.
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- Web Update

NNPBC Office: #500 - 3777 Kingsway, Burnaby, BC V5H 3Z7 | Phone: 604-737-1304 (All calls Toll Free across Canada & the United States) | Email: info@nnpbc.com

Membership form 2021

Contact Information

School Information

Communication Preferences