Application Form

Name                                                                                                                          

Title                                                                                                                            

Address                                                                                                                        

City/Province                                                                                                                 

Postal Code                                                                                                                    

Office Telephone                                                 Home Telephone                                        

E-mail                                                                Fax                                               

Previous CIHR  Relationship:  (please check category and indicate year)

___ Student ___ Scholar     ___ Fellow    ___ Centennial Fellow    ___ Clinician-Scientist Fellow

___ MRC Scientist    ___ Visiting Scientist    ___ Career Investigator    ___ Friend

Would you like to participate in any of the following activities: (please check)

___ Regional meetings    ___ Meet with M.P.’s and M.P.P.’s    ___ Standing committee

___ Meet the president    ___ Membership      ___ International project    ___ Finance

___ Fund raising    ___ Communications    ___ Business Development     

___ Other (specify)                                            

   I                                  , support Friends of  CIHR and would like to
           become a member: (please check one of the following)

    Regular Member: A cheque of $50 is enclosed.

    Charter Member: A cheque of $70 is enclosed.

    Corporate Member: A cheque of $1,000 is enclosed.

Click here for Downloadable Form!
Complete and return with payment to:
Friends of Canadian Institutes of Health Research
c/o GG441 Health Sciences Centre
820 Sherbrook Street
Winnipeg, Manitoba R3A 1R9
Canada