Registration form for 2024 CORNQ members
CONFIRM YOUR INFORMATION BEFORE SUBMITTING
| Personal Information |
| CORNQ's Membership Number : | Empty |
| Gender : | Empty |
| Name : | Empty |
| First Name : | Empty |
| Address : | Empty |
| City : | Empty |
| Province : | Empty |
| Postal Code : | Empty |
| Phone Number : | Empty |
| Personal Email : | Empty |
| Professional Information |
| Name of Integrated Health and Social Services Centre or Employer : | Empty |
| Establishment : | Empty |
| Address : | Empty |
| City : | Empty |
| Province : | Empty |
| Postal Code : | Empty |
| Work Phone : | Empty |
| Extension : | Empty |
| Job Title / Function : | Empty |
| Specify if Other : | Empty |
| Professional Email : | Empty |
| Credit Card Information |
| Firstname : | |
| Name : | |
| Postal Code / Doctorate : | |
| Card number : | |
| Expiration date : | |
| CVV : | |
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| 2024 CORNQ provincial conference registration |
| Number of days : | Empty |
| Days of presence : | Empty |
| Allergies or dietary restrictions |
| Empty | Empty |
| Total : | Empty |
| Replacement / already paid : | Empty |
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TOTAL PAYMENT : | Empty |
Are all information correct ?
Currency : All payments are in Canadian dollars only.
Cards accepted : You can complete transactions using Visa or MasterCard.
Privacy Policy : The CORNQ site is secured with SSL standard and, through their highly secure connections, Desjardins and Optimal, ensure the confidentiality of information that you submit during the transaction. All personal information collected will be used only for the payment of sites and enrollment management and will, under no circumstances be sold to any third party.
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