Membership Application Form

Note: Membership goes from June 1 to May 31 and any membership taken BEFORE May 1 will EXPIRE on May 31.

Please indicate

New member

Renewal

Surname

First Name

Street

City

Province/State

Postal Code

Telephone

CONA Chapter

Type of Membership

RN/LPN/RNA ($100/yr)

Other: OT / PT / ortho tech ($75/yr)

Student (Undergraduates only) ($50/yr)

Retired ($35/yr)

1. Professional Status

Other

2. Level of education

Diploma-Nursing

Baccalaureate-Nursing

Baccalaureate-other

Masters

Doctorate

Other

3. Area of Practice

Adult Orthopaedics (In-Patient)

Paed. Orthopaedics (In-Patient)

Operating Room

Clinic

Ambulatory Care (Out Patient)

Other

4. Position

Staff nurse

Head nurse

Clinical nurse specialist

Nursing administrator

Other

5. Employment Status

Full Time

Part Time

Casual

Not Employed

Retired

6. Do you belong to the C.N.A.?

Yes

7. Do you belong to another special interest group?

Yes

Enter a Password (used to login to Members only section)

Re-type Password

Your credit card will be charged 100.00. This will appear as "CANADIAN ORTHOPAEDIC NURSES" on your statement.

Card Number ---

Expiry (MM/YY)

Type