Online Registration

Nurse Practitioner Association of Manitoba

Membership Application Form - September 01, 2009 to October 31, 2010


Fields marked with * are required.
First Name*
Last Name*
Mailing Address*
City*
Province*
Postal Code*
Daytime Telephone*
Other Telephone
Email*


Employment Information
Health Authority you work for or work in* 

Employer #1
Practice Area*
Primary Care  
Acute Care  
Emergency  
Long Term Care  
Other  
If other, please list
Work Setting*
Urban  
Rural  
Northern  
Do you work*
Full Time  
Part Time  

Employer #2
Practice Area
Primary Care  
Acute Care  
Emergency  
Long Term Care  
Other  
If other, please list
Work Setting
Urban  
Rural  
Northern  
Do you work
Full Time  
Part Time  

NP Education (General Members)
From what institution did you receive your NP education?*
What year did you graduate as an NP?*

Nurse Practitioner Students
Which program are you enrolled in?
What is your anticipated graduation year?


Membership Type*
General ($50.00)
Student ($25.00)