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

    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?
    YesNo


    We invite your comments!

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