Membership Application Form

CSIH Membership Application
(Due to a technical problem we cannot accept this form electronically. Please print it and fax it to (613) 241-3845)

Membership Categories^*

*Select one option in the box (All fees are in Canadian dollars)*
Direct membership The Society offers a two-year membership for its direct members. If you wish to take advantage of this, please select one of the choice beside and return the form with appropriate payment. This offer does not apply to conjoint membership. Applicants for organizational* membership should complete two forms, identifying the primary and secondary contact in the organization.
Conjoint membership*with the Canadian Public Health Association (for individuals only)* Provides full membership in CSIH and CPHA.
Supporter and Benefactor Membership: Income tax receipts will be issued for both supporter and benefactor categories for the deductible amount of the contribution (ie: $50, for Supporter, $150, for Benefactor).

METHOD OF PAYMENT:^*

^*Cheque or Money Order
^*Please make cheque payable to the Canadian Society for International Health

VISA (No other credit cards)

VISA Card (only) Number: (Print only):

Expiry Date:

Name of Cardholder:

Signature:

(Due to a technical problem we cannot accept this form electronically.
Please print it and fax it to (613) 241-5785) or mail it and your payment to:

CANADIAN SOCIETY FOR INTERNATIONAL HEALTH
One Nicholas St., Suite 1105
Ottawa, ON K1N 7B7 Canada
Tel: (613) 241-5785 Fax: (613) 241-3845
Charitable Registration # 88999-3077-RR001

Full Name (Please print):	^*
Title:
Employer:
Address:	^*
City:	^*
Province:
Postal Code:
Country:	^*
Residential Telephone:	Area Code:
Residential Fax:	Area Code:
Business Telephone:	Area Code:
Business Fax:	Area Code:
E-mail:	*

Membership Categories*

Membership Categories^*