Canadian Journal Addiction Medicine - Canadian Harm Reduction ...

2012 Membership Form
Membership Type
Regular Member – MD Regular Member – PhD Scientists Medical Student/Intern/Resident
Retirees – MD or PhD Associate Member
Contact Information
Dr. Ms. Mrs. Miss Mr.
Name:
(First Name) (Middle Initial) (Last Name)
Work Address Preferred Mailing Address
Address:
City: Province: Postal Code:
Work Phone:
Home Address
Fax:
Preferred Mailing Address
Address:
City: Province: Postal Code:
Home Phone:
Email Contact*
Email Contact* (please provide password you would like)
Are you interested in Canadian Certification in Addiction Medicine? (Member – MD only) Yes No
Positions in the Society You Would Be Willing To Consider in the Future
Board Member (Please note: Associate members are not eligible for board positions)
Committee
Membership:
Standards Website Opioid Agonist
Education Membership Conference
I will allow my name & contact information to be in a password-protected
Member’s Section directory on the CSAM webpages?
Yes No
Signature:
Annual Fees
Regular Member – M.D.: $200.00 Student/Intern/Resident: $5.00
Regular Member – PhD : $200.00 Retirees MD or PhD: $25.00
Associate Member: $50.00
Optional: International Society of Addiction Medicine (ISAM) Dues – (US $100.00 effective January 2011) $100.00
PLEASE process payment for: One year 3 years $549.00 5 years $900.00
*TOTAL PAYMENT: $
Cheque, Bank Draft or Money Order Payable to: The Canadian Society of Addiction Medicine or
VISA/Master Card (circle one) #
Expiry Date
Name on Card:
Signature:
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