Membership Registration – The Nurses Shopping Mall

Full Name *

First

Last

Town/City of Residence *

Region of Residence *

Home Address *

(include neighbourhood, street address and house number)

Email *

Phone Number *

Name of Hospital or Clinic Stationed *

Town/City of Hospital or Clinic *

Region of Hospital or Clinic *

ID Number *

Voters, Driver's License, National ID or Passport.

GRNMA Membership ID Number *

Upload Signed and Scanned ID Card (Voters, National ID, Passport, Driver's License) *

Click or drag a file to this area to upload.

Scan, print, sign, and then scan and upload the scanned softcopy here.

Upload Passport Picture

Click or drag a file to this area to upload.

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