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Change of Address Form
All items marked with (*) must be completed relative to your choice of address to modify.

Female Male
Last name (*)

First name (*)

Status : Student ResidentPractician

Collège des médecins du Québec permit number (*) or # QMA Student member


Effective date of address change:


Check the address(es) to be changed:
New home address
  Address (including apt. no. if applicable) (*)

City (*)
 
Province (*)
Country (*)
Postal Code/Zip (*)
Telephone (*)
  
Mobile Phone
Email


Address of new office or hospital
  Name of new office or hospital (*)

Address (*)

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


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.