Application For Change Of Membership Category
Canadian Association of Physical Medicine and Rehabilitation 774 Echo Drive Ottawa ON K1S 5N8 Fax: (613) 730-1116
Name:
Address: Postal Code
Telephone: Fax: E-mail:
Date of Birth (M/D/Y): Sex: M F
Provincial medical licensure
Province: Year:
Type (if spec. register):
Specialist qualifications
Qualifications: Year:
Granting body:
Specialty:
Change of category desired
From: Ordinary Associate, Medical Scientist Associate, Non-specialist Corr.
To: Ordinary Associate, Medical Scientist Associate, Non-specialist Corr.
Signature of applicant: ____________________________
Date: __________
