Waerea ki te ara ki te Ora - Leading the way towards total well-being

Te Kaunihera O Nga Neehi Maori O Aotearoa
National Council of Maori Nurses

MEMBERSHIP REGISTRATION FORM
 
STUDENT NURSES & HEALTH WORKERS
 
1 April 2010 – 31 March 2011

PERSONAL DETAILS:

Surname:

First Names:

Private Address:

Private Phone:

Private Fax:

Private Mobile:

Private Email:

Iwi Tribal Affiliations:

Hapu:

Whanau:

EMPLOYMENT DETAILS:
Employer:

Job Title:

Training Institution:

Name of Course:

Postal Address:
Physical Address:
Business Phone:
Business Fax:
Business Mobile:
Business Email:
Student Nurse / Health Worker National Fee $  20.00
Indemnity Insurance (Optional) Please Contact Admin Unit for more details 
Total Amount Enclosed Cheque / Cash $

Are you a Branch Member:

Yes    No
Name of Branch:

Print this form before submitting and send a copy with your cheque payable to:
National Council of Maori Nurses

PRINT THIS PAGE

OR

Pay by Automatic/Direct Credit to:
National Council Maori Nurses Aotearoa
Kiwibank, Papamoa
A/c No: 38 9007 0262418 00


SIGNED: ……………………………………………………………

DATE:………………...