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 make cheque payable to CACMID or pay dues using your VISA card (Mastercard is not accepted) by completing the information below:

Name as it appears on the card:


Card Number:


Card Expiry Date:


If required, please cheque to:

Astrid Petrich, CACMID Secretary-Treasurer
St. Joseph's Healthcare
St. Luke's Wing Rm L424
50 Charlton Ave E, Hamilton ON L8N 4A6
Tel: 905-522-1155 x 32700
Fax: 905-521-6083
E-mail: petricha@mcmaster.ca


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