Application Information

See attached business card

Surname:

Given Names:

Organization :

Title/Job Description:

Phone: (   ) 

Fax: (   )

Email:

Street Address:

City/Town:

Postal Code:

Preferred Mailing Address:            as above OR:

Street Address:

City/Town:

Postal Code:

Phone: (   )

Fax: (   )

Email:

Professional Information

Profession:

           (4)

MD

Nurse

Other (specify):

Interest Area: (4)

Research

Education

Other (specify):

Pre-travel

Post-travel

Annual Membership Dues :(4)

Voting: $100.00

Non-voting: $50.00

Administrative Use Only:

Voting A

Voting B

Non-voting