Membership Application

The VMS Application Form is for Physicians only.

To apply for membership in the Victoria Medical Society, please complete the form below. 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. Required fields are in bold.

Date of This Application:

Full-Name

CPSID#

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

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

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!

Leave a Reply