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Application for new membership or renewal 2012
Membership Application
  I hereby apply for membership to the Quebec Medical Association and the Canadian Medical Association, with all the privileges attached to such membership. I agree to be governed by their constitutions and bylaws and to observe their Codes of Ethics.
Renewal Application
  If you are renewing your membership, enter only your last and first name, your permit (license) number, your status, your e-mail, your membership category and answer the “Go Green” question.

For any change of address, complete the CHANGE OF ADDRESS form if your contact information has changed since your last renewal.

If this is a new membership, all items marked with (*) must be completed.

Female Male
Last name (*)

First name (*)
Date of birth: 

Status: Student Resident Practician

Doctor of Medicine:
University   
 
Collège des médecins du Québec permit number

 
  General Practitioner    Specialist
Specialist: (Indicate specialization)

 
Year you began your studies: University :
In year of residency. University:
In year of medicine. University :
Have you completed one year of pre-medicine?:
  Yes   No
Graduation year: or anticipated year of graduation:

Home address
Address (including apt. no. if applicable) (*)

City (*)
 
Prov./State (*)
Country (*)
Postal Code/Zip (*)
Telephone (*)
  
Fax
Email


Name of office or hospital (if any)
Name of office or hospital

Address (*)

City (*)
 
Province/State (*)
Country
Postal code/Zip
Telephone
  
Fax
Email


Membership fees

Member category Annual fees Monthly
instalment
Regular member $730 $60.84
1st year of practice $515 $42.92
**Part-Time Practice $465 $38.75
Post-graduate member $319 $26.59
Retired member $286 $23.84
Resident $129 $10.75
Student $20 n/a
 

Your membership is valid for 12 months, beginning the month you became a member.

** Because of: Work/Family Conciliation, partial disability, end of career or personal reasons.
Proof: The physician must write a letter to confirm the number of hours he works, along with his signature.


Method of payment
Pre-authorized payment
  Your account will be debited every month.
Please, fax a sample cheque marked "VOID" to number (514) 866-0670.



 
 

Transit no.

Bank no.

Account no.
 
Full payment by credit card
 
  Visa
  MasterCard
Card no.
 
Expiration date
Payment date
 
Please bill me.

Correspondence
  English   Home
  French   Office

Go Green with the QMA
Would you like to receive your renewal notice by email ?

  Yes, I want to go green.
Here is my email address :
  No, I would like to receive it on a paper copy.

To get to know you better, please take a few moments to answer the questions below. Thank you for your cooperation.

1- Please indicate the type of institution where you practise. (Check as many as necessary)
Exclusively in institutions (CSSS, CLSC, CHU, etc.)
Exclusively outside institutions (office, practice, clinic)
In and outside institutions
Public health
Private practice outside the RAMQ
Other, specify :
2- Does your position involve medical administration ? (DSP, clinical director, department head, etc.)
Yes, specify :
No
3- Would you be interested in taking part in any boards, committees or working groups at the QMA?
If so, please indicate your areas of interest. (Check as many as necessary)
Steering committee (conventions, symposiums, training)
Governance committees (board, audit, etc.)
Political issues (legislation, ministerial policy directions, etc.)
Professional issues (medical organization, professional autonomy, interdisciplinary, information technology, etc.)
Ethical issues (right to die with dignity, assisted reproduction, opioid use, etc.)
Economic issues (financing, mixing medical practice, clinical performance, etc.)

The QMA-CMA members list is confidential. The Association does not share it with any other organization, with the exception of its official partners who offer services to its members. If you do not wish to receive these offers of services, please advise us. As a QMA member, you automatically become a member of the CMA. For physicians who join the QMA/CMA, contact and demographic information provided on this form will be shared with the CMA and used in accordance with CMA's Corporate Privacy Policy. For a copy of CMA's Corporate Privacy Policy, visit www.cma.ca, then go to "Privacy" in the footer on the home page.