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Get Csnm Membership Renewal Form

441. 0591 e-mail csnm csnm.ca Website www. csnm.ca RENEWAL APPLICATION FOR ACTIVE MEMBERSHIP NOTE THIS APPLICATION MUST BE COMPLETED IN ITS ENTIRETY SIGNED DATED AND SUBMITTED WITH PAYMENT PRIOR TO CONSIDERATION. FOR ADDITIONAL INFORMATION ON THE CSNM PLEASE VISIT OUR WEBSITE AT www. Name Appearing On Card Date of Expiry Card Number AUTHORIZATION I authorize CSNM to charge to my credit card Signature of Card Holder Month Year Coming in 2010 All renewing CSNM Active Members are required to maintain 8 CE Continuing Education points 1 each in the 8 core competencies yearly to ensure their membership renewal is accepted. For more details visit www. Fees cannot be prorated refunded or transferred. Members will be required to pay a 75. 00 reinstatement fee in addition to their annual membership fee if payment is received after April 15th CSNM Membership Year - April 1st- March 31st Employment Status Full-time Unemployed Part-time Casual Employer Type Acute Care Mental Health Supplier Public Health Self Employed Health Spa LTC Corrections Other Organization Name Current Position City/Town Province Signature Date Please ensure the 165. 00 renewal fee is enclosed with your application. Payment by cheque or money order postal or bank payable to Canadian Society of Nutrition Management or by Credit Card. 300-1370 Don Mills Road TORONTO ON M3B 3N7 PH. 416. 441. 9622 Toll Free 1. 866. 355. CSNM 2766 Fax 416. csnm*ca* Please Print First Name Middle Initial Last Name Street Address City/Town/Province Membership Number Postal Code Telephone e-mail Address Renewals are due on or before April 1st to ensure uninterrupted service. Fees cannot be prorated refunded or transferred* Members will be required to pay a 75. 00 reinstatement fee in addition to their annual membership fee if payment is received after April 15th CSNM Membership Year - April 1st- March 31st Employment Status Full-time Unemployed Part-time Casual Employer Type Acute Care Mental Health Supplier Public Health Self Employed Health Spa LTC Corrections Other Organization Name Current Position City/Town Province Signature Date Please ensure the 165. 00 renewal fee is enclosed with your application* Payment by cheque or money order postal or bank payable to Canadian Society of Nutrition Management or by Credit Card. csnm*ca* Please Print First Name Middle Initial Last Name Street Address City/Town/Province Membership Number Postal Code Telephone e-mail Address Renewals are due on or before April 1st to ensure uninterrupted service. Fees cannot be prorated refunded or transferred* Members will be required to pay a 75. 00 reinstatement fee in addition to their annual membership fee if payment is received after April 15th CSNM Membership Year - April 1st- March 31st Employment Status Full-time Unemployed Part-time Casual Employer Type Acute Care Mental Health Supplier Public Health Self Employed Health Spa LTC Corrections Other Organization Name Current Position City/Town Province Signature Date Please ensure the 165.

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