General Information:

First Name:

Last Name:

Medical School:

Year of Graduation:

Current Position:

Base Speciality:

Attending Staff Resident/Fellow

Hospital:

Address:

City/Town & Province/State:

Postal/Zip Code:

Business Telephone:

Business Fax:

Email:

Do you wish to be added to the CCCS discussion email list?

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Please list two active CCCS members we may contact to support your application.

MEMBERSHIP FEES:

Full Member
Attending Staff

$ 200/Year

Affiliate Member Residents and Fellows

$ 25/Year

Would you like to make a contribution to the Canadian Intensive Care Foundation?

$100 $250 $500 $1000

Other

Membership Fee

Gift to Research (CICF)

Total

PAYMENT OPTIONS:

Cheque:

• Payable to: The Canadian Critical Care Society

Internet Banking or Credit Card

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