AGM Application

AGM registration

Title:

First Name:

Last Name:

Address:

City:

Province:

Postal Code:

Country:

Tel (Office):

Ext.

Tel (Home):

Fax:

Email Address:

Fees:

Non-Members	$350.00
Full member/Associate	$200.00
Retired or Honorary/Senior member or 1st/2nd year in practice	$175.00
Resident members	$75.00
Student members	$50.00

Complimentary (as authorized)	$0.00
Saturday Soirée X tickets	$100.00
Student sponsorship (optional)	$
Total	$

Special requirements including dietary:

Method of Payment: