PNP Membership Form

As members of ACTION PNP each and every one of us is committed to improving the lives of People with Neuropathic Pain.

*Name (Surname Given Name Initial)
*Gender	M  F
Address
City
*Province	Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Postal code
Phone home
Phone work
Cell
Age group	18-35  36-55  55+
*There are two types of membership on the PNP committee	Regular members who are elected to serve on the PNP committee  Associate members who support the activities in meeting the goals and mandates of ACTION Ontario
*Please check applicable designation	people diagnosed with Neuropathic Pain  people who wish to support the initiatives of ACTION Ontario/PNP  people who work with people with Neuropathic Pain and wish to support the initiatives of ACTION Ontario/PNP
*Email
Referred by

There is no fee for joining ACTION Ontario/PNP.

Privacy Statement: the information collected on this form is for ACTION Ontario/PNP membership only and will not be shared with other parties for commercial or other usage.

Print form for off-line application