Click here to print this form.

Name: ________________________________________________________________

Your Title/Position : _____________________________________________________________

Company Name: _______________________________________________________________

Company Address:___ __________________________________________________________

City: ______________________________   Prov./ State: _______________________________

Country: ___________________________   Area Code/Zip: ____________________________

Telephone: _________________________    Fax: ____________________________________

Contact information if different from aboe Company Address:

Address:___ __________________________________________________________

City: ______________________________   Prov./State: _______________________________

Country: ___________________________   Area Code/Zip: ____________________________

Telephone: ______ _________________   Fax: _______________________________________

Preferred Email address: ______________________________

How long have you been in the Insurance industry? ____________

Describe your job activities and how you are involved in the Insurance industry.
_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

If part time, how much of your time is devoted to Insurance work? ________ Hours/week

What other appointments have you held? (Insurance company, industry, University, etc.) _____________________________________________________________________

From which medical school and in what year did you graduate?_______________________________

Are you licensed to practice medicine in the jurisdiction where you work? _______________________

What is your field of specialization in clinical medicine (if any)?
_______________________________________________________________________________

Certificates held/ Fellowships:

Program/Year: ____________________________________________________________________

Program/Year: ____________________________________________________________________

What is your field of specialization in insurance organizations?
__________________________________

What memberships do you hold in other medical and insurance organizations?
_____________________________________________________________________________

CATEGORY of  CLIMOA MEMBERSHIP APPLIED FOR:  (See Categories and Fees link at left)

______________________________________________________     ___________________________
Your signature                                                                                            Date

When completed this application should be sponsored by two Association members and then forwarded
to the secretary of the association – address below.
Sponsor 1
Member name: ________________________________ Company______________________________

Contact phone/email___________________________________________________________________

How do you know this person? __________________________________________________________

______________________________________________________   ____________________________
Signature                                                                                                  Date

Sponsor 2
Member name: ________________________________ Company ______________________________

Contact phone/email___________________________________________________________________

How do you know this person? __________________________________________________________

______________________________________________________   ____________________________
Signature                                                                                                  Date

If you do not have sponsors who know you in CLIMOA, please forward the name and contact information
of 2 persons in other Insurance Medicine organizations, such as the American Academy of Insurance Medicin (AAIM), the American Council of Life Insurers (ACLI) or from within your company, clinic, or faculty.

TO APPLY FOR MEMBERSHIP IN CLIMOA, PLEASE RETURN THIS FORM WITH YOUR CHEQUE FOR THE APPROPRIATE FEE FOR THE CATEGORY OF MEMBERSHIP YOU ARE APPLYING FOR, OR WITH ANY QUESTIONS, TO:
CLIMOA Secretary
C/O Unconventional Planning,
32 Colonnade Road, Unit 100
Ottawa, ON K2E 7J6

OR BY EMAIL: climoa@unconventionalplanning.com