Name:

Address:


City / Province / Postal Code

Telephone: Fax:

E-mail:

Date of Birth (M/D/Y): Sex: M F

Send correspondence in English French

Medical school, degree, and year:

PM&R training (university and year):

Anticipated year of completion:

Other university degrees:
a)
b)

Associate  - $150
Associate/Resident - $20
Medical Students - no charge

Cheque enclosed (payable to CAPM&R)

Visa     MasterCard #

Expiry Date:

Signature of applicant: ____________________________

Date: ________________________