Workplace Representative Information Form

Full Name:
RN Number:
 
Address Line:
City/Town:
Province:
Postal Code:
 
Email Address:
Phone:
 
Place of Employment:
Health Region:
Position:
Please contact us if any of this information changes in the future.

I agree that the above information will be shared with other SRNA Workplace Representatives involved in this program.
 
1. Are you interested in receiving a mail out of information 6X year and e-mails?
Yes No
 
2. Will you post/share this information with RN's at your workplace?
Yes No
 
3. What kind of information would you like to receive from us?
 
4. How many RNs will you be sharing SRNA communiqués with?

THIS INFORMATION WILL ONLY BE USED FOR SRNA PURPOSES AND WILL NOT BE SHARED WITH THIRD PARTIES WITHOUT YOUR CONSENT.

If you have any questions or would like more information please contact:
Deanna Makarchuk
Ph: 1 800 667 9945 ext 234 or in Regina 359 4234
Fax: 306 359 0183
Email: dmakarchuk@srna.org

Last Updated: May 4, 2008

2066 Retallack St.
Regina, Saskatchewan
Canada S4T 7X5