Application for
Membership Friends of Canadian Institutes of Health Research was established in 2000 as the successor
organization to Alumni and Friends of the Medical Research Council of
Canada.
The objectives of Friends of CIHR are:
To achieve these goals FCIHR recruits individuals across all health disciplines and beyond.
Information:
(Completion of this form ensures FCIHR records are accurate and current. Your personal and professional data is used only for the sharing of FCIHR information with you and is not published, distributed or provided to any other parties without your express permission.)
Name: __________________________________________________________________________
Title: ___________________________________________________________________________
Department: _____________________________________________________________________
Organization: _____________________________________________________________________
Mailing Address: ___________________________________________________________________
City & Province: ___________________________________ Postal Code: ______________________
Ph: (____) ______-__________ ext______ Fax: (____) ______-__________
E-mail: _________________________________________________________
Previous Relationship (if any) to CIHR and its Councils and Committees (check all that apply):
[ ] Graduate Student [ ] Centennial Fellow [ ] Clinician-Scientist Fellow [ ] Career Investigator [ ] Grantee
[ ] member of IAB [ ] other ______________________________________________
________________________________________________
____________________________
Signature
Date
Invoice for Membership Dues:
Memberships are effective for one calendar year (January to December) and are payable in the preceding year:
Charter membership: $75.00 _____________
or
General membership: $50.00 _____________
Additional Voluntary Contribution: _____________
Total remittance: _____________
Please return this form with your cheque made payable to:
Friends of Canadian Institutes of Health Research