Société Canadienne de Phlébologie
Canadian Society of Phlebology
RENEWAL AND APPLICATION FOR MEMBERSHIP
Identical to last year
Name
Last / First / Middle / Initial
Office address:
Street
City / Province
Postal code / Zip
Home address:
Street
City /Province
Postal code / Zip
Office Phone
Fax
Home Phone
E-mail
Degree Medical School
Certifications
Type of practice in Phlebology
Surgery / Non invasive test / Sclerotherapy /
Invasive testing
Date
:
Year / Month / Day
Dues are in the amount of $ 350 and renewable every year at the beginning of January.
Make your check payable to the Canadian Society of Phelobology and send to the
following address:
424, du Domaine, Saint-Bruno, Quebec J3V 2S4
Tel / Fax (514) 990-8346 (VEIN)
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Copyright © 2002 Canadian Society of Phlebology
All rights reserve
The American College of
Phlebology
Société Française de
Phlébologie
Springer Verlag
