2012/2013 ONSA MEMBERSHIP FORM (May 1, 2012 – April 30, 2013)

1. 2012/2013 ONSA 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:_____________________________________________________________________________________________________________ 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) 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. (Information on the membership list falls under the provisions of the Freedom of Information of Privacy Act) 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 OHN Catalyst Paper 201-65th Front street Nanaimo, BC V9R 5H9 Occupational Nurses’ Specialty Association ONSA of British Columbia