CAGPO - Membership Form

CAGPO - ACMOO MEMBERSHIP FORM

You would prefer to send your registration by mail ? CLICK HERE to download the form to send out.

*Greeting

Mr. Mrs. Ms. Dr. Prof.

*First name

*Last name

Title

Department

*Organization

*Phone number

Fax

*Email

*Address 1

Address 2

*City

*Postal/Zip Code

*Country/Region

*Province/State

Billing address

As it appears on your credit card statement

Same as above

*Address 1

Address 2

*City

*Postal/Zip Code

*Country/Region

*Province/State

CAGPO Privacy Policy

CAGPO may provide your contact information to cancer agencies and other organizations for the purposes of informing you of cancer-related educational events or publications that the Executive of CAGPO has reviewed and feels would be of interest to our membership.

*Do you wish to have your contact information shared in this way

Yes No

PAYMENT

Membership Fees

Full and part time clinician	$100
Retired clinician	$50
Medical student and family medecine resident	Free

*Please select your membership category for 2019

Clinician ($100) Retired clinician ($50) Student/resident ($0)

*CAGPO may provide your contact information to cancer agencies and other organizations for the purposes of informing you of cancer-related educational events or publications that the Executive of CAGPO has reviewed and feels would be of interest to our membership.

CHECK HERE if you wish to have your contact information shared in this way

CHECK HERE if you DO NOT want to have your contact information shared this way

Total

Please select your payment method:
(Cheques, Visa and MasterCard are accepted)

*Card number

*Name on the card

*Expiration

*Card Security Code (CVC)

Transactions by credit card will appear under AGORA COMMUNICATION on the credit card holder's statement. A confirmation notice will follow shortly.