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Surname:
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First Names:
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Private Address:
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Private Phone:
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Private Fax:
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Private Mobile:
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Private Email:
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Iwi Tribal Affiliations:
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Hapu:
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Whanau:
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Nursing Registration
Certificate Number:
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Occupation:
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Practising Non Practising
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EMPLOYMENT DETAILS:
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| Employer: |
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| Physical Address: |
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| Business Phone: |
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| Business Fax: |
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| Business Email: |
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| Registered Nurse National Fee |
$100.00 |
| Indemnity Insurance (Optional) |
Please contact the admin unit for more information |
| Total Amount Enclosed |
Cheque / Cash $ |
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Are you a Branch Member:
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Yes No |
| Name of Branch: |
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Print this form before submitting and send a copy with your cheque payable to:
National Council of Maori Nurses
OR
Pay by Automatic/Direct Credit to:
National Council Maori Nurses Aotearoa
Kiwibank, Papamoa
A/c No: 38 9007 0262418 00
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SIGNED: ……………………………………………………………
DATE:………………...
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