Membership Update - Mobile - Rural General Practice Network

Membership update form

Name (person completing this form)*
First Last
Email*
Phone*
Practice name*
Practice address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please select your membership type*
- Practice
- Individual Full Member
- Associate Member
What is your work status?*
Work status - other*
Please state*
Practice staff list for NZRGPN membership
- Please note that with ‘Practice Membership’, each of your staff is included as a member. GPs and nurses have Full Membership with voting rights and all other staff have Associate Membership.
- To enable us to communicate directly with members, please supply the following information for each staff member: name, role, start date (if within the last 12 months), email address.
- As a minimum, we require names and e-mail addresses for all GP and nurse members to enable us to distribute membership information and voting papers for our Annual General Meetings.
- You can provide this information by uploading an Excel file from your desktop, OR please complete the form below.
Select the total number of staff at your practice*
If you have selected Practice, from the above drop-down, select the total number of staff at your practice. Please complete the staff list below(click + to add more rows) or upload an excel document containing the details as displayed in the form below.
Select a method to submit staff list*
- Download excel template, complete and upload
- Fill the information online
Click here to download the practice staff list template
Upload your completed Excel file here*
Accepted file types: xls, xlsx, xlsm, xlsb, xml, Max. file size: 5 MB.
Only excel formats xls, xlsx, xlsm, xlsb, xml are accepted. The maximum file size allowed is 5MB
Practice staff list for NZRGPN membership*
First Name Last Name Role E-mail address
Individual Full Member - Please state profession/status*
Please note: Individual Full Members are with voting rights: GP, NP, practice nurse or rural hospital doctor or nurse
Profession/status - other*
Associate Member - Please state profession/status*

Please note: Associate Members are without voting rights and include: medical or nursing students, midwives, other health professionals (whose scope of practice is under HPCA Act), practice/hospital managers, friends, affiliate organisations.

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First Name	Last Name	Role	E-mail address

Practice staff list for NZRGPN membership