Victoria Medical Society: Membership Application

The Victoria Medical Society
Eric Martin Pavilion
190-2334 trent Street
Victoria bC V8R 4Z3
tel: (250) 598-6021
fax: (250) 370-8274
email: administrator

The VMS Application Form is for Physicians only.

To apply for membership in the Victoria Medical Society, please complete this form and click on Submit Form. Your application will be reviewed and voted upon by the executive at the next monthly meeting. You will be notified of the results of the vote, either by email or by regular post.

Shortly thereafter, each successful applicant will receive an invoice in respect of the membership fee. Upon receipt of your payment you will be considered a full member of the Victoria Medical Society and will be entitled to all membership benefits.

In order to ensure the privacy of your information, this form is processed via secure servers. Required fields are in bold.

Date of This Application:

I, , (Insert Full Name) being a member in good standing of the College of Physicians and Surgeons of British Columbia, do apply for membership in the Victoria Medical Society.

By entering my CPSID# in the following box I signify that I shall abide by the Society By-laws, Rules and Regulations.

Office Address
Office City
Office Postal Code
Office Phone
Office Fax (if available)
Office Email (if available)
Office URL (if available)
Home Address
Home City
Home Postal Code
Home Phone
Home Fax (if available)
Home Email (if available)
Field of Practice
Date of Birth	(mm/dd/yy)
Place of Birth

Primary/Secondary Education at:

Premedical Training at:

University Medical Training (location/years):

Postgraduate Education:

Type of Practice:

Special Medical Interests:

Memberships/Positions (Medical):

Memberships/Positions (Community):

Hobbies/Interests:

Spouse's Name/Children's Ages (if applicable):

Military Service:

Languages Spoken:

Opportunities to Serve on Committees

The VMS Executive would appreciate your assistance by indicating your interest in the following functions of the Society. Please take a moment to consider these opportunities:

Please select a number from 1 to 5:
1 = not at this time; 5 = very interested

Continuing Medical Education
Archives
Pemberton Memorial O/R Restoration
VMS Newsletter
Programme/Social Planning
Would you be interested in serving on the Executive Committee? (Yes/No)

We invite your comments!

Please click Submit Form only once

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