CANADIAN ADULT CONGENITAL HEART NETWORK

CACH MEMBERSHIP & DIRECTORY INFORMATION

To become a member of the Canadian Adult Congenital Heart Network you must fully complete the form below to be considered. All fields are required.

CONTACT INFORMATION

First Name:			Last Name:
Address:			City:
Province:			Postal Code: (e.g. M4N3Z1)
Country:			Email Address:
Telephone 1: (e.g. 519-333-3333)			Telephone 2: (e.g. 519-333-3333)

BACKGROUND

Medical Degree (if applicable):			Year:
University Degree 1 (if applicable):			Year:
University Degree 2 (if applicable):			Year:
Where Are You Currently Working?:

PROFESSION

Adult Cardiologist Pediatric Cardiologist Cardiac Surgeon Nurse
Other (please specify in "Professional Qualifications")

PROFESSIONAL QUALIFICATIONS

NAMES OF TWO SPONSORS (optional) - Sponsors should be CACH Network Members.

1.
2.

Note: Annual Fee of $100 (Fellows-in-training and non-physician members are exempted).

If you prefer to mail or fax your application, please print this form and mail to:

CACH Network
6835 Century Avenue, 2nd Floor
Mississauga, Ontario, L5N 2L2
Tel: 905.826.6665
Fax: 905.826.4873