Associate Member – Medical Student/Resident/Fellow Associate Membership for Medical Student, Resident or Fellow costs $51.50/yr NON-VOTING Price: $51.50 billed each year [NON-VOTING] First Name:* First Name Required Last Name:* Last Name Required Address Line 1:* Address Line 1 is Required Address Line 2: Address Line 2 is not valid City:* City is Required Country:* Country is Required -- Select Country -- Canada Afghanistan Åland Islands Albania Algeria Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belau Belize Benin Bermuda Bhutan Bolivia Bonaire, Saint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo (Brazzaville) Congo (Kinshasa) Cook Islands Costa Rica Croatia Cuba CuraÇao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Republic of Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Norway Oman Pakistan Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Martin (Dutch part) Saint Pierre and Miquelon Saint Vincent and the Grenadines San Marino São Tomé and Príncipe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia/Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom (UK) United States (US) Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Wallis and Futuna Western Sahara Western Samoa Yemen Zambia Zimbabwe State/Province:* State/Province is Required Zip/Postal Code:* Zip/Postal Code is Required Organization: Organization is not valid Phone:* Phone is Required Phone extension: Phone extension is not valid I can confirm that I am: I can confirm that I am is not valid Medical Student in Canada Resident or Fellow in Canada Medical School of Graduation: Medical School of Graduation is not valid Year: Year is not valid Other (Please specify): Other (Please specify) is not valid COMMUNICATIONI consent to receiving emails and other communications from the CSPM pertaining to my membership and to the information, activities, surveys and events of the Society. I understand that I may withdraw my consent at any time by contacting office@pallmed.ca:* COMMUNICATIONI consent to receiving emails and other communications from the CSPM pertaining to my membership and to the information, activities, surveys and events of the Society. I understand that I may withdraw my consent at any time by contacting office@pallmed.ca is Required Yes No I consent to receiving occasional research surveys issued by palliative medicine residents and other non-commercial palliative care researchers: I consent to receiving occasional research surveys issued by palliative medicine residents and other non-commercial palliative care researchers is not valid Yes No Email:* Invalid Email Password:* Invalid Password Password Confirmation:* Password Confirmation Doesn't Match Cheque and remittance form Credit Card Pay with your credit card via Stripe No val Please fix the errors above
