Date of Birth  January February March April May June July August September October November December 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925

Do you wish to be placed on the Maori Roll?

no yes

Membership Type Fellow RN Documentation Required - $510pa / $42.50 Fellow NP Documentation Required - $750pa / $62.50 Member RN - $510pa / $42.50pm Member NP - $750pa/$62.50pm Member RN working under 20hrs p/w - $390pa / $32.5 Member NP working under 20hrs p/w - $564pa / $47.0 Member RN in full time study - $390pa / $32.50pm Member NP in full time study - $564pa / $47.00pm Member RN Retired - $260pa / $22.00pm Member NP Retired - $260pa / $22.00pm Member RN - No Insurance Cover - $460.00pa / $38.5 Member NP - No Insurance Cover - $510.00pa / $42.5

And (please tick):

Workforce Development Policy Development / Review Curriculum Development Career Development Mentoring Preparation of Submissions Nursing / Health informatics Community Involvement Leadership / Management Education Portfolio Development Legal Issues Working with the Media Research Report Writing

Please select from the options below:

Internet Search Facebook Nursing Review publication Nursing Review website Workshop flyer/email Referred by College of Nurses Member/s (please enter names below) Other (please state below)

Membership applications must contain full, current and accurate information.

The College of Nurses Aotearoa (NZ) membership support and professional indemnity insurance do not come into effect for any performance issues, complaints or investigations which occurred prior to the application being approved and membership confirmed.

I have read and understood the statement above.

Profile Information

The following information will display on your public profile.

Do you provide cultural supervision for Maori nurses

Yes No

Supervision provided by:

Skype Facetime Teams Zoom Telephone Face to Face Other

Do you Travel to the supervisee if local? Yes No

Format of supervision:

Individual Group

Professional Registration:

Registered Nurse Nurse Practitioner

Declaration

I declare that the information provided above regarding professional nursing supervision for CNA (NZ) approval is accurate and correct. By completing and electronically signing this form I agree to the terms and conditions laid down by the CNA (NZ).

Date  January February March April May June July August September October November December 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925

Amount to Pay: Contact Office