CAGPO - Membership From

CAGPO - ACMOO MEMBERSHIP FORM

*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

*Province/State

Billing address

As it appears on your credit card statement

Same as above

*Address 1

Address 2

*City

*Postal/Zip Code

*Country

*Province/State

*Date of birth :

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 2016

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

Total

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

*Card number

*Name on the card

*Expiration

*Card Security Code (CVC)