MEMBERSHIP FORM SOCIETY OF GERONTOLOGY NURSES AND CARERS OF ASIA INC. 1x1 picture Drop a file here or click to upload Choose File Maximum upload size: 134.22MB Date of Entry: PERSONAL INFORMATION Last Name * First Name * Middle Name * Date of Birth * Age Sex MALE FEMALE Civil Status SINGLE MARRIED WIDOWED DIVORCED Current Address Current Address Current Address Current Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Email Address Contact No. * EDUCATIONAL BACKGROUND Add Education Background Degree Program Baccalaureate Associate Trained Certified Others.. (Please Specify) Others Years Attended School/Institution/University Add Remove WORK EXPERIENCE Employed at the Moment? YES NO Add Work Experience Position Institution Year Add Remove AFFILIATIONS/ORGANIZATIONS/INVOLVEMENTS Affiliations/Organizations/Involvements Are You an Active PNA member? * YES NO PNA NO. * EXPIRY DATE * IDs should be a month valid before the expiration date. Are you a Holder of PRC ID/License? * YES NO PRC NO. * EXPIRY DATE * IDs should be a month valid before the expiration date. Front ID * Drop a file here or click to upload Choose File Maximum upload size: 10MB Back ID * Drop a file here or click to upload Choose File Maximum upload size: 10MB Other Government Issued IDs * SSS/GSIS ID POSTAL ID TIN ID DRIVERS LICENSE ID OTHERS Front ID * Drop a file here or click to upload Choose File Maximum upload size: 10MB Back ID * Drop a file here or click to upload Choose File Maximum upload size: 10MB Submit If you are human, leave this field blank.