O.A.G.S. MEMBERSHIP FORM
-
NEW FISCAL (Sept.01/08-Aug.31/09)
Note: This pertains to general surgeons/ residents/ fellows ONLY.
Please fill out and print this registration form. Following this, you can mail it with payment to:
O.A.G.S., P.O. Box 192, Stn Main, Peterborough, ON K9J 6Y8.
Date:
1) Name:
2) Year of Birth: (Re. Calculating ave. age)
3) Primary Hospital:
4) Office Mailing Address:
5) City:
6) Province:
7) Postal Code:
8) Office Phone#:
9) Office Fax#:
10) Email:
11) Status Category:
Choose a category
Active General Surgeon (billing OHIP)
Inactive (no longer billing OHIP)
Resident
Fellow
Out-of-Province/Country
12) Subspecialty:
Choose a category
breast
cardio
colorectal
cosmetic/plastic
crit care
endoscopy
ENT
ERCP
fractures
head/neck
hepatobiliary
laparoscopy
ob/gyn
oncology
ortho
pancreatic
pediatric
thoracic
thyroid
transplant
trauma
urology
vascular
Other Subspecialties:
13) Registering for Annual Mtg 2008?:
Yes
No
14) Registering for evening banquet?:
Yes
No
15) Calculate Dues & Meeting Fee:
(Refer to
dues
/
agm
table.)
Membership Dues
(400,100,or 10...resident memberships were discounted courtesy of Covidien)
$
Annual Meeting Fee
(This is free to members after dues.)
$
Evening Banquet/Wine Tasting Fee
($50 for members and non-members)
$
Total AMOUNT TO REMIT:
$
SIGNATURE: