PANBC Membership Application

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Membership application / Renewal form

Full name *

Last, First

Address *

City *

Postal Code *

Phone number *

Facility of employment *

Position *

E-mail address *

By signing up for membership, you are consenting to receiving e-mails from PANBC, including our signature newsletter

PANBC #

For renewal only

Are you currently a Registered Nurse? *

Yes

What type of membership would you like? *

Active $25

Renewal $25

Associate (non-RN) $15

Student $10

NAPAN# (leave blank if you are unsure)

Would you be interested in becoming a regional representative?

You would be involved in distributing the newsletter; putting up posters in your practice area (no spam will be sent)

Yes

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Submit

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