SASKATCHEWAN THORACIC SOCIETY - Membership Form

NAME:_____________________________________________________________________

PREFERRED ADDRESS: Home ____ Business ____

Address_____________________________________________________________________

City ______________________________ Province ____________ Postal Code___________

PHONE:

Home:________________ Work:________________ Fax:___________________

PLACE OF WORK:___________________________________________________________

POSITION:__________________________________________________________________

DISCIPLINE CATEGORY:_________

D = Dietetics N = Nursing OT = Occupational Therapy
PH = Pharmacy MD = Physician PT = Physical Therapy
RT = Respiratory Therapy SW = Social Work O = Other

PLEASE INDICATE YOUR CHOICE OF MEMBERSHIP BY CHECKING THE APPROPRIATE SPACE:

• ___ 1 Year Membership = $20.00 (January 1, 2002 - December 31, 2002)
• ___ 3 Year Membership = $50.00 (January 1, 2002 - December 31, 2004)

FEE ENCLOSED:

Cheque ____

Visa/Mastercard ________________________________________ Exp.Date:__________

Signature (if paying by credit card)________________________________________________

I am interested in being a resource for:_______

S = Speaking at Seminars P = Program Planning C = Committee Work
D = Document Review O = Other

Please mail or fax your forms to:
The Saskatchewan Lung Association, 1231 - 8^th Street E, Saskatoon, S7H 0S5, (306) 343-7007.
If you have additional questions, please call us at 343-9511 (Saskatoon) or 1-800-667-LUNG.

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