Unit 915 Le Gran Condominium, Eisenhower Street, Greenhills, San Juan, Metro Manila

Website: www.ornap.org---Email Ad: mailornap@yahoo.com , CP #: 0921-433-0572

MEMBERSHIP FORM 2x2 ID Photo for

LIFETIME only

REGULAR ASSOCIATE LIFETIME

First Name : Middle Name : Last Name : Title : RN, MAN, PhD

Age/ Gender: B-date / Civil Status: ORNAP Member since:

PRC No.: Valid Until: Registration Date:
Institution:
Institution Address
Position : Inclusive Dates: Area of Assignment:
Email Add : Mailing Address:

Contact No.

Beneficiary To be filled up by ORNAP Only

Name: ORNAP ID No.
Relation: Amount paid: Date:
Address: Processed by: OR No.:
In compliance with the Data Privacy Act, consent is likewise given to release my information to legally authorized third
party including PR-Board of Nursing but not limited to partner organizations, healthcare industry companies or nurse
employer/sponsor, I authrorize the Organization to furnish from the records requested information or excerpts thereof to
any legally authorized entity that is responsible for the processing of data.

consent for the use of my information to be informed and

I consent I do not consent be updated of the activities / services of ORNAP
consent for the use of my information for research and
training purposes for the improvement of perioperative
I consent I do not consent nursing practice

I have read this consent and I have understood all the conditions here in. In view of this, I voluntarily assume the risk and
hold OPERATING ROOM NURSES ASSOCIATION OF THE PHILIPPINES, (ORNAP) Inc. from any liability that may arise there
from.

Name & Signatute of Applicant/ Date

MEMBERSHIP CATEGORIES:
A. Regular Member - A Perioperative Nurse who currently manages, mentors, practices perioperative nursing
B. Associate Member – a perioperative nurse engaged at least in the following
                         i.          Perioperative nurse educator

                       ii.          Perioperative research

                    iii.          Overseas employment

                    iv.          Private duty nursing

C. Life members - Any active perioperative nurse who signifies membership for life and pay the dues in the
amount determined by the Board and has been a regular member for five consecutive years and attended five
successive Annual Convention and General Membership Meeting.
Rev 2019-2020-4