Associate Member

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Personal Information

* Username

* Password

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* Ttile

* Dr.

* First Name

* Family Name

Preferred First Name for Correspondence

Middle Name

* Preferred Language

English

* Date of Birth

* DD/MM/YY

Gender

Male

Spouse Name

Race

Sexual Orientation

* Membership Category

Active Member

I am a member of CAUS and agree to include CAUS dues in my invoices.

Phote

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Biography

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Contact Information

* Email Address

Alternative Email

Office Phone

Fax

Home Phone

Mobile Phone

* Preferred Milling Adress

Home Infromation

Country

Country

* Address

Suite/Unit

City

Province

Postal Code

Work Information

* Country

Country

Business Name

* Address

Suite/Unit

* City

* Province

* Postal Code

Privacy Setting

It is optional to exclude the following information from the membership directory.

I do not wish to have my information shared with respect to third parties (PIPEDA).

I am willing to be on a media contact list.

Discussion Forum

Your preferred name will be displayed by default for all forum topics and comments posted by you. You may create your own forum username if you do not wish to have your real name displayed with your posts/replies. Deleting the username below will change all of your posts/replies back to display name.

Forum Display Name

Physician Information

* Year of MD

* Medical School (MD)

Royal Collage ID #

* Certified By

* Year of Certification

* Practice Description

Practice Type

Additional Professional Credentials

Name of Affiliated Principal Hospital

Name of Affiliated University

Conducting Clinical Research

* Subspecialties

Residency and Fellowship

Please enter your residency and fellowship information, if applicable.

Residency University

Residency Completion Date

YY/MM

Fellowship University

Fellowship Completion Date

YY/MM

Fellowship specialty