The Occupational Health Nurses Association Of Ireland
Membership Application Form
 PLEASE COMPLETE IN BLOCK CAPITAL LETTERS.
Forename: _______________________________________________
Surname: _______________________________________________
Home Address: _______________________________________________
Contact Number: _______________________________________________
E-mail Address: _______________________________________________
Place of Employment: _______________________________________________
Work Address: _______________________________________________
Job Title: _______________________________________________
Work Contact Number: _______________________________________________
Work E-mail Address: _______________________________________________
 Have you ever been a member of the OHNAI : Yes    No
Nursing Qualifications /
O.H. Experience:

R.G.N.      O.H.N.

Other: _________________________________________

Occupational Health Student

University/College: _______________________________
 
Indicate your preferred contact address:

Home       Work
 

On occasion we are contacted by OHNAI members requesting contact details of all members for OHN research studies, please indicate your preference below:

I agree to the OHNAI providing my contact details to other OHNAI members for OHN based research studies.

I do not agree to the OHNAI providing my contact details to other OHNAI members for OHN based research studies.

Yearly subscription is €40 and is from November to November. Payments can be made by cheque, postal order or bank draft made payable to OHNAI Please forward completed application and subscription fee to: OHNAI, P.O Box 5616, Dublin 8.
Members, please be aware that the OHNAI is coordinated by the committee on a voluntary basis and as such we appreciate your patience in allowing a reasonable period of time for your receipt for membership being issued, thank you in advance.
Signature: _____________________________    Date: ______________________