IMPORTANT: I have read and agree to the RULES AND PROCEDURES FOR MEMBERSHIP.

Agree      Disagree

Type of Application:

  Member ($60.00 + $5.00 application fee)
Associate ($50.00 + $5.00 application fee)

First Name:

Middle Name:

Last Name:

Home Address (R.R.#, P. O. Box or Street):

Town or City:

Province:

Please Choose Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

Postal Code:

Work Address (R.R.#, P. O. Box or Street):

Town or City:

Province:

Please Choose Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

Postal Code:

Home Phone:

()

Work Phone:

()

Fax:

()

Email Address:

Name of Supervising Physician:

Number of Years Training:

Place of Training:

Year of Registration:

Certificate#:

Professional Designations (R.E.T., R. EP T., etc):

Language of Correspondance Preferred:

English      French

Preferred Place of Correspondance:

Home      Work

Spoken Language(s):

English      French     Both

I wish to be included in the membership directory:

Yes      No

I wish to become a CAET volunteer:

Yes      No