I hereby certify that the statements and information in my application form are true and correct to the best of my knowledge and belief.

I understand that the Canadian Nurses Protective Society (CNPS) may verify any of the information provided on this form. By signing this form, I authorize the CNPS to investigate all statements of information contained in it. I understand and agree that any misrepresentation, falsification or material omission of information on this form may result in denial or revocation of my beneficiary status with the CNPS.

I understand that the personal information that I provide will be used by the CNPS without consent or further authorization for transactional purposes (for instance, to contact me in reference to a request for assistance, or to provide me with important information related to CNPS services, or my eligibility for these services), or to provide information about important changes in the law or nursing practice.

I understand that by identifying myself as a member of a provincial nursing association, I authorize the CNPS to share my information with the association to verify my membership status.

I understand that I must report a change of personal information (name, contact information, professional nursing designation, etc.) to the CNPS at the earliest opportunity. In particular, if I am or if I become a nurse practitioner (NP), I must register with the CNPS as such so that I benefit from liability protection for professional activities within the NP scope of practice.

I understand that my eligibility for CNPS core services (and, if I applied for it, Supplementary Protection) will be conditional upon being a CNPS beneficiary and having a valid licence or registration to practise nursing at the time of the events giving rise to the inquiry, claim or legal proceeding.

I have read the excerpts of the CNPS Bylaws related to the provision of assistance. I understand that CNPS assistance is granted on a discretionary basis, and that each request for assistance will be considered on a case by case basis in accordance with the applicable practices and procedures of the Society.  I also and understand my obligation to report any threat, claim, complaint, legal proceeding or adverse event related to my nursing practice to the CNPS at the earliest opportunity and collaborate with the CNPS in all instances where assistance is granted.

I understand that CNPS services and, in particular, the provision of professional liability protection and legal assistance do not generally extend to my professional corporation or business entity.

I understand that professional liability protection is required as a condition for practice in most Canadian provinces and territories. By submitting this application, I authorize the CNPS to confirm to my nursing regulatory body and to my employer or institution where I practise or seek to practise nursing that I am a CNPS beneficiary and eligible for CNPS professional liability protection.