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    Fees Form     
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Canadian
Life Insurance Medical Officers Association
L'association canadienne des directeurs medicaux en assurance-vie Application for membership ---Click here to print this form. Name: ________________________________________________________________ Your Title: _____________________________________________________________ Company Name: ________________________________________________________ Address:___ ___________________________________________________________ City: _________________________________________________________________ Prov/State: ____________________________________________________________ Zip: _______________________ Tel: ______ _________________ Fax: ______ __________________ Email: ______________________________ How long have you been with the company? ____________ If part time, how much of your time is devoted to insurance? _______________________ What other appointments have you held? (Insurance co., industry, university) _____________________________________________________________________
From which medical school did you graduate?__________________________________ Year of graduation? __________________ What is your field
of specialization in clinical medicine (if any) Certificates held/ Fellowships Year: ____________ Year: ______________ What is your field
of specialization in insurance organizations? What memberships do
you hold in other medical and insurance organizations?
Date: _________ Signature: _______________ When completed this
application should be sponsored by two association members and then Sponsor Company _____________________ _________________________ _____________________ ________________________ Return to: Dr. Kim Minish
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