Family Name


First Name


Title


Department


Affiliation


Degrees


Address


City


Province/State


Country


Code (Postal/Zip)


Telephone Number


Fax Number


E-mail Address


The Board Members have passed a motion to post a membership directory on the CACMID web site and to make this list available to reputable companies.

If you DO NOT wish to have your name and affiliation listed, please write "YES" here:



Membership Fees

Please choose one of the following options:



Please make cheque payable to CACMID or pay dues using your VISA or Mastercard by completing the information below:

Name as it appears on the card:


Card Number:


Card Expiry Date:


If required, please forward cheque to:

CACMID Secretary Treasurer
Dr. Matthew W. Gilmour

Chief, Enteric Diseases, National Microbiology Laboratory, Public Health Agency of Canada
1015 Arlington Street, Winnipeg, MB R3E 2R2
Tel: 204.784.5920(o) + 204.781.0549(c); Fax: 204.789.5012
Matthew_Gilmour@phac-aspc.gc.ca


PLEASE PRINT THIS PAGE BEFORE SUBMITTING IF YOU WANT A HARD COPY FOR YOUR RECORDS PRIOR TO THE RECEIPT BEING MAILED.