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If you are an existing member, please click here to renew your membership application and do not fill out the New Member Application below

New Member Application

Title:
First Name:
Last Name:
Address:
 
 
City:
Province:
Postal Code:
Country:
Tel (Office): Ext.
Tel (Home):
Fax:
Email Address:
Branch Region:
Yes, you may share my coordinates (name, address, email, phone number, fax number) with other FMWC members as required for completion of FMWC business.
No, you may not share my coordinates with other FMWC members.
Membership Categories:
Prices are in Canadian funds
Medical Student: $25.00
Associate Student: $25.00
Resident: $50.00
Retired: $50.00
Out-of-country: $50.00
Associate: $75.00
1st/2nd Year in Practice: $85.00
Full Membership: $150.00
How did you hear about the FMWC?
A member suggested I join (member’s name):
Would you be willing to be interviewed by the media on behalf of the FMWC? Yes
No
Specialty:
Areas of interest:
For Medical Students
Degree(s):
Area(s) of special interest/expertise:
Would you please consider a donation to (click on the fund for more information):
Maude Abbott Fund Donation: CDN$
Maude Abbott Research Fund Donation: CDN$
Method of Payment:  
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