Name:

Address:


City / Province / Postal Code

Telephone: Fax:

E-mail:

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

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Medical school, degree, and year:

PM&R training (university and year):

Postgraduate training (university and year):

Other university degrees:
a)
b)

Licensure (province and type of licence):
a)
b)

Fellowships, certificates, diplomas:

Position(s) and appointments:

Particular areas of interest:

Indicate which committee you would consider joining in the future:

Education
Research
Scientific program
Continuing Professional Development
Communications
Finance

Indicate which Special Interest Group (if any) may apply to your particular area of interest:

Amputee
International
Medical Education
Medical Legal
Neuromuscular
Pediatric
Spinal Cord Injury
Stroke
Traumatic Brain Injury

Active Member - $350

Corresponding Member (non-resident of Canada) - $100

Cheque enclosed (payable to CAPM&R)

Visa     MasterCard #

Expiry Date:

Signature of applicant: _____________________ Date: _____________