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CAGPO - ACMOO MEMBERSHIP FORM
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Greeting
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Mrs.
Ms.
Dr.
Prof.
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First name
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Department
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Address 1
Address 2
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City
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Postal/Zip Code
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Country/Region
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Zimbabwe
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Province/State
Alberta
Colombie-Britannique
Île-du-Prince-Édouard
Manitoba
Nouveau-Brunswick
Nouvelle-Écosse
Nunavut
Ontario
Québec
Saskatchewan
Terre-Neuve-et-Labrador
Territoires du Nord-Ouest
Yukon
Billing address
As it appears on your credit card statement
Same as above
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Address 1
Address 2
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City
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Postal/Zip Code
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Country/Region
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Mauritania
Mauritius
Mexico
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Korea
Norway
Oman
Pakistan
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
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Province/State
Alberta
Colombie-Britannique
Île-du-Prince-Édouard
Manitoba
Nouveau-Brunswick
Nouvelle-Écosse
Nunavut
Ontario
Québec
Saskatchewan
Terre-Neuve-et-Labrador
Territoires du Nord-Ouest
Yukon
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Date of birth :
Step 2: Questions
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Please indicate how long you have worked as a general practitioner in oncology (GPO), whether part time or full time :
Please select
Less than 2 years
2 to 5 years
6 to 10 years
11 to 19 years
20 or more years
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Wich best describes your affiliation with the College Family Physicians of Canada (CFPC) ?
Please select :
Certificant (CCFP)
Member of the CFPC
Both certificant and member
None of the above
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Please specify in which areas of oncology you provide care as a GPO. Please check all that apply.
Teaching residents
Teaching medical students
Administration
Systemic therapy
Radiation therapy
Genetics/High Risk clinics
Pediatric cancer care
Surgical cancer care
Gynecological cancer care
Inpatient Care
Clinical trials
Symptom Management/Palliative Care
Other (please specify)
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Please specify the disease sites for which you provide care as a GPO. Please check all that apply :
Breast
Lung
Hematologic Malignancies
Pediatrics
Head and Neck
Skin / Melanoma
CNS
Pain and Symptom Management
Gynecological
Gastrointestinal
Genitourinary
Other (please secify)
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Outside of GPO work, what medical activities do you routinely participate in ? Please choose all that apply :
Only working as a GPO
Community Family Practice
Locum Family Practice
Surgical Assists
Speciality clinical work
Administration
Teaching
Palliative Medicine/Symptom Management
Research
Hospital Medicine
Other (please specify)
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Assuming a 1.0 FTE is based on regular daytime hours, 40 hours work week, please estimate your full-time equivalent status for ALL MEDICAL ACTIVITIES you perform as a physician, including work as a GPO. This number may be greater than 1.0.
Please select :
2.0 FTE or more
1.9 FTE
1.8 FTE
1.7 FTE
1.6 FTE
1.5 FTE
1.4 FTE
1.3 FTE
1.2 FTE
1.1 FTE
1.0 FTE
0.9 FTE
0.8 FTE
0.7 FTE
0.6 FTE
0.5 FTE
0.4 FTE
0.3 FTE
0.2 FTE
0.1 FTE
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Assuming a 1.0 FTE is based on regular daytime hours, 40 hour work week, please estimate your full-time equivalent status for ALL MEDICAL ACTIVITIES you perform AS A GPO only.
Please select :
2.0 FTE or more
1.9 FTE
1.8 FTE
1.7 FTE
1.6 FTE
1.5 FTE
1.4 FTE
1.3 FTE
1.2 FTE
1.1 FTE
1.0 FTE
0.9 FTE
0.8 FTE
0.7 FTE
0.6 FTE
0.5 FTE
0.4 FTE
0.3 FTE
0.2 FTE
0.1 FTE
Step 1 : Personal Information
Step 3 : Fees
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.
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Do you wish to have your contact information shared in this way
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No
PAYMENT
Membership Fees
Full and part time clinician
$100
Retired clinician
$50
Medical student and family medecine resident
Free
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Please select your membership category for 2019
Clinician ($100)
Retired clinician ($50)
Student/resident ($0)
Step 2 : Questions
Step 4 : Payment
Total
Please select your payment method:
(Cheques, Visa and MasterCard are accepted)
Please select
Cheque
MasterCard
Visa
Free of charge
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Card number
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Name on the card
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Expiration
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21
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25
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35
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39
40
41
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Card Security Code (CVC)
Step 3 : Fees
Submit