Membership Plan

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Correspondence

Preferred Mailing Address In accordance with federal regulations effective January 1, 2004, the CAG is required to keep confidential all personal information provided by its members (unless authorized otherwise), and to disclose how this information will be used.
Company Name (if applicable)
Street
City
Province/State
Postal Code/Zip
Country
Share Info with CDHF	Yes No
Receive Newsletter	Yes No
Receive Correspondence	Yes No
Receive Journal	Yes No
Allow Database Search	Yes No
Receive Survey Requests	Yes No
Home Phone
Office Phone
Cell Phone

Education

Education Details
Present Position (Trainee Members Only)	Gastroenterology Resident Internal Medicine Resident Clinical Fellow Medical Student Post-doctoral Fellow Graduate Student Undergraduate Student Other
If other, please specify
Expected Date of Graduation/Completion of Training (Trainee Members Only)
Name of Undergraduate Institution
Graduated/Expected Graduation Date
Undergraduate Degree
Name of Medical/Postgraduate Institution
Graduated/Expected Graduation Date
MD/Postgraduate Degree
Other Institution
Other Degree Graduation Date
Other Degree
Internship/Residency Location #1
Inclusive Dates (e.g. 2001-2003)
Internship/Residency Location #2
Inclusive Dates (e.g. 2001-2003)
Additional Training Location
Inclusive Dates (e.g. 2001-2003)

Sponsor/Credentials

Nominating CAG Sponsor Details To be considered for CAG membership, this application must be seconded by a Regular CAG member in good standing. By providing the name of my Nominating Supporter on this application, I allow my application to be viewed by them.
Nominating CAG Sponsor
Credentials Please submit at least one of the following files: for physicians, a copy of your license to practice, certificate, appointment letter for trainees, a letter from your program director (for residents and fellows) or your supervisor (for basic science trainees).
File Upload 1
Your file must be of zip, rar, doc, pdf, txt, xls type. Your file should not exceed 3 MBs. Select file By uploading, you certify that you have the right to distribute this file.
Your file must be of zip, rar, doc, pdf, txt, xls type. Your file should not exceed 3 MBs. Select file By uploading, you certify that you have the right to distribute this file.
Your file must be of zip, rar, doc, pdf, txt, xls type. Your file should not exceed 3 MBs. Select file By uploading, you certify that you have the right to distribute this file.

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