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GENERAL INFORMATION |
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Mailing Address: |
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Office Home |
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Prefix : |
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*First Name: |
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Middle Name: |
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*Last Name: |
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Academic Degrees: |
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Title: |
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Organization/Company : |
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Department : |
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*Mailing Address 1: |
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Mailing Address 2: |
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*City: |
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*Province: |
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*Postal Code: |
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*Email Address:
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*Confirm Email :
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*Office Phone: |
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Fax: |
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*Home Phone: |
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CATEGORY |
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Specialty: |
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Other Specialty: |
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MEMBERSHIP FEES
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2012 2013 |
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Affiliate Membership: Students, patients & their families $50.00 |
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Affilfiate Membership: Corporate $180.00 |
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Active Membership: Nurses, Program Coordinators, Technicians, and other non-physician healthcare professionals $180.00 |
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Active Membership: Scientists and Physicians $250.00 |
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Total (GST/HST not applicable) |
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PAYMENT OPTIONS
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Credit Card charges are processed by Neuromodulation.ca
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*Type : |
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*Credit card number : |
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*Expiration date : |
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(YYMM) |
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*CVN |
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*Name on the Credit Card: |
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QUESTIONS
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Paula Chiasson, T: 902-473-7809, F : 902.473.7808, E: paula.chiasson@cdha.nshealth.ca
CNS Website: www.neuromodulation.ca INS Website: www.neuromodulation.comction |
