MEMBERSHIP REGISTRATION
Personal Information
First Name:
Middle or Maiden Name:
Last Name:
Gender:
Select Gender
Male
Female
Date of Birth:
Marital Status:
Select Marital Status
Single
Married
Divorced
Widowed
Marital Names:
Professional Information
District:
Hospital:
Organization:
Role:
Nurse
Midwife
Nurse Status:
Serving
Retired
Student
Membership Registration Date:
Nurses Council Number:
National ID:
Contact Details
Contact Number:
Email:
Employment Number:
Employing Institution:
Government
Private
NGO
Date Joined:
Next of Kin Information
Next of Kin Name:
Relationship:
Contact Number:
Email:
Profile Image
Profile Image:
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