Local Branch *

Have you been a member of the IPNA within the past 2 years? *

First Name *

Surname *

Name of GP Employer *

Home Address *

Work Address *

*You must be working with a GP to qualify for membership. If you are doing Locum work, please name one GP you have worked for within the past 12 months

Tel (home)

Tel (work) *

Mobile Phone

Would you like to receive text alerts from the National Executive Committee (NEC)?* *

Would you like to receive e-mail alerts from the National Executive Committee (NEC)?* *

*i.e. Relevant info via IPNA Admin, e.g. Alerts from health agencies, disease outbreaks, courses, discussion boards, etc.

Preferred mailing address for IPNA use (Including Journal) *

Do you give us permission to pass on your work contact details (Address and telephone number) to your local Professional Development Coordinator for Practice Nurses?

If you would like to receive information by post from outside bodies on issues relevant to practice nursing, to your preferred mailing address, please tick here:

I would like to receive this information

This information may relate to education, study days, continuing professional development, products or services that are deemed by the National Executive Committee to be relevant to the role of the Practice Nurse.

Nursing & Midwifery Board of Ireland (formerly An Bord Altranais) PIN number *

Professional Qualifications (NMBI Divisions)

RGN

RM

RSCN

RPN

RMHN

RNID

RPHN

RNP

Further Education (please specify, e.g. Diploma Asthma, Higher Diploma in Practice Nursing)

I.F.P.A Cert in Family Planning

Other Nursing Certificates

Diploma

Degree

Higher Diploma

Masters

Nursing Grade

CNS

ANP

Year CNS Accredited

Year ANP Accredited

Special Interest Areas

Women's Health

Asthma

Diabetes

Cardiovascular Disease

Other special interest? (please specify)

Hours worked per week

Union Membership

INMO

SIPTU

IMPACT

Medical Indemnity

MDU

MEDISEC

Medical Protection Society

Email *

Repeat Email *

Choose a Password *

Membership Level *

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