2010 Member Information
* Indicates a required field 

Gender*

   Male  Female

Salutation*

   Dr. Mr. Mrs. Ms.

First Name*

Last Name*

New Member*    Returning Member
Accreditation*
Accompanying field must be filled as well --->
MD Specialty/Practice area:

PhD

 Discipline

RN

 Practice

Other

Please specify


Interests

Please specify areas
of research interest:
Please write a maximum
one page introduction
letter including a brief description of your general interests or activities in hepatology.   (*for new members this is a required field):


Current Mailing Address
Address Type* Home Address  Business Address

Institution

Address*

City*
Province*
Postal Code*
International , (Region, Country)

Telephone*

Fax Number

E-mail Address*

E-mail Address2


Membership Information*

All Membership Dues are paid in Canadian Funds
Membership Dues are paid for the period of January to December

5 Year Membership 2010-2014

  $ 800.00
Regular Membership  $ 200.00
International Regular Membership
(outside of Canada & United States)		  $ 200.00
Associate Membership  $ 50.00
Emeritus Membership  FREE
* Student/Trainee Membership
(up to a maximum of three years)

  FREE
Graduate Student 
Resident/Fellow
Post-Docs

* Please supply a letter from your program director or supervisor authenticating your status. Please note that the letter MUST be signed by your program director or supervisor before your application can be processed; letters that are not signed will not be accepted. If you have this letter available as a JPG or PDF file, upload it below.

I would like to make a donation to the Canadian Liver Foundation in the amount of:

I would like to receive my copy of the Canadian Journal of Gastroenterology in *
French English

I do not wish to receive a copy of the Canadian Journal of Gastroenterology

I do not wish to become a member of the IASL
(International Association for the Study of the Liver)

I do not wish to receive a copy of 'Liver International'
(applies to Regular Membership & 5 year Membership only)

I am currently an active member of *
(please select all those that apply)

IASL   CAG
I am not an active member
of CAG or IASL


Payment Options*

 Mail in a cheque - Cheque Number:
Please print this form and mail it in with your cheque to:

CASL, 34 Eglinton Avenue West, Suite 323, Toronto ON M4R 2H6

* Please make cheque payable to: "The Canadian Association for the Study of the Liver"


 Visa  Master Card  American Express

Card Number (no spaces)
Expiry Date (no spaces)
Card Holder's Name
Authorization*  By clicking this box I authorize The Canadian Association of the Study of the Liver to charge the above credit card in the amount of the total indicated above.
Reciept Required: Yes  No
Total*  Canadian Funds

 

 * Indicates a required field