1. No category

MEMBERSHIP FORM
Thank you for choosing a retired nurse membership with the Canadian Nurses Association. Please complete
the form below. Online registration is also available at join.cna-aiic.ca.
Confirm past registered nurse status
To validate your past RN status, complete any two of the following:
1.
Province or territory where you were licensed as an RN*
2.
RN number
3.
Nursing school you graduated from
4.
Year of graduation
*If you currently maintain a licence to practise as an RN, you do not qualify for a retired nurse membership with CNA.
Member Information
First Name
Last Name
Address Line 1
Address Line 2
City
Province/Territory
Postal Code
Telephone
E-mail
Payment
Your retired nurse membership fee includes applicable taxes based on your current place of residence.
Province/Territory
AB, BC, MB, NT, NU, QC, SK, YT
NB, NL, ON
PE
NS
CNA GST/HST registration No.: 106864549RT0001
Fee
$54.95
$54.95
$54.95
$54.95
Tax
$2.75
$7.14
$7.69
$8.24
Total
$57.70
$62.09
$62.64
$63.19
With your membership payment, you’ll be a CNA member from January 1 to December 31, 2015. For the remainder of 2014, please enjoy your CNA membership on us!
l have enclosed a cheque/money order (payable to the Canadian Nurses Association)
Please charge to my: Visa / MasterCard (circle one)
Card Number
Expiry Date (MM/YY)
Cardholder’s Signature
Name on Card
Please return this form by mail or fax:
Canadian Nurses Association, 50 Driveway, Ottawa, ON K1P 1E2, Tel.: 1‐800‐361‐8404, x262, Fax: 613‐288-5205 cna-aiic.ca