Membership Form

All information collected is stored securely and will not be shared outside of the CPCNA.

The information collected below will be used exclusively for the purpose of the work of CPCNA . We will not share your information with third parties.

If you are unsure which membership type applies to you, please email cpcnamembers@gmail.com before purchasing to avoid having to refund and submit correct payment.

Membership fees are due annually (January to December):
- Full Nurse Membership- $100 (plus transaction fees- $103.30)
- Retired/Non-Practicing Nurse Membership- $50 (plus transaction fees- $51.75)
- Entry to practice program student rate- $ 25 (plus transaction fees- $26.25)

Member #

First Name

Last Name

Street Address

City

Province

Postal Code

Position/Role

Province/ Territory of practice

Practice Registration Number (School of Nursing if student) (Retired/non-practicing, enter 555555)

Enter certification number

Areas of Interest/Interest in Committees

I agree contacted by CPCNA

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