First Name

Last Name

Address Line #1

Address Line #2

City

Postal Code

Email

Phone Number

Employer (confidential)

Job Title

Designation DesignationLPNRNNPOther

Level of Education Level of EducationDiplomaBachelorMastersOther

New or Returning Member New or Returning MemberNew MemberReturning Memeber

What zone do you work in? What zone do you work in?EasternCentralNorthernWestern

Payment method Payment methodE-Transfer (Preferred)PayPal/Credit CardCheque in the mail

I give FPNANS/CFPNA permission to use my contact information for the purpose of receiving communication from FPNANS/CFPNA, as well as receiving information about relevant educational, research, or committee opportunities.