Registration form for 2024 CORNQ members

Terms of payment
We suggest reading first the terms of payment that you will have to accept.

	New registration
	Replacing a registration Subscribe to replace: Confirmation number * : -

Personal Information

CORNQ's Membership Number * :

Mrs.

Mr.

Name * :

First Name * :

Address * :

City * :

Province * : --- Select a province -- Alberta British Columbia Prince Edward Island Manitoba New Brunswick Nova Scotia Nunavut Ontario Quebec Newfoundland and Labrador Saskatchewan Northwest Territories Yukon

Postal Code * :

Phone Number* :

Personal Email* :

Professional Information

I don't have professional Informations

Name of Integrated Health and Social Services Centre or Employer* :

Address * :

City * :

Province * : --- Select a province -- Alberta British Columbia Prince Edward Island Manitoba New Brunswick Nova Scotia Nunavut Ontario Quebec Newfoundland and Labrador Saskatchewan Northwest Territories Yukon

Postal Code * :

Work Phone :

Extension :

Job Title / Function * : Select your job title ORNAC BOARD CORL RN RN CPN(C) TEAM LEADER RNFA EDUCATOR AHN MANAGER Other

Specify if Other  :

Professional Email  :

Credit Card Information

Four last digits of credit card number* :
**** **** ****

This information is only used as a reference. You will need to enter the full credit card number on the payement page.

I pay with my credit card (corresponds to my personal information)

I pay with a different credit card

Credit Card Holder Information

Name * :

First Name * :

Email* :

Package description : *

Cost for 1 day of conference:. CA $ 150.

Dates	Hours	Friday May 28, 2021
3:30 p.m. to 9 p.m. :	Can$ 545	Can$ 595
Saturday May 29, 2021 :	Can$ 520	Can$ 520
7:30 a.m. to 6 p.m. :	Can$ 260	Can$ 260

Thursday October 10th, 2024

Friday October 11th, 2024

Saturday October 12th, 2024

Registration for the mixology workshop on Saturday, May 29, 2021 at 5 p.m. *

I will be present (Can$ 0 / ticket)

Ticket(s) extra for the friday evening party (Can$ 0 / ticket) * :

Participation to the mixology workshop : No ticket

Number of participants who wants a vegetarian menu:

I will not be present

Warning: count(): Parameter must be an array or an object that implements Countable in /home/ciisoqca/public_html/wp-content/themes/bulledev-boilerplate/php_data/questions_supp.php on line 10

Warning: count(): Parameter must be an array or an object that implements Countable in /home/ciisoqca/public_html/wp-content/themes/bulledev-boilerplate/php_data/questions_supp.php on line 25

I accept the terms of payment stated on this site.

Total : Can$ 0
Replacement / already paid : Can$ 0

TOTAL PAYMENT : Can$ 0

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.