Central Service Association

MEDICAL DEVICE REPROCESSING ASSOCIATION OF NOVA SCOTIA (MDRANS)

MEMBERSHIP APPLICATION $40.00 Membership fees are payable in full for 2 years Due: November 1, 2016.-expires October 31, 2018 Name: (Last)______(First)______

Current MDRANS member: Yes ( ) Please provide membership number______No ( ) Last year of membership______

Home Address Street City/Province Postal Code Home Phone

Hospital/Employer Name______Street City/Province Postal Code Work Phone

Email Address

Present Position Technician Education Clinical Resource Management Other

MDRT Certification: Yes ( ) Through Whom: ______No ( ) Currently Enrolled in an educational program: Yes ( ) No ( ) If yes, please explain ______Status Full-Time Part-Time Casual Retired Other

Highest Academic Achievement: ______

Signature: ______Date: ______

Mail Membership Application and cheque to: Barbara Young Dartmouth General Hospital Sterile Processing Dept. 325 Pleasant Street, Suite 1706 Dartmouth Nova Scotia B2Y 4G8