CSIH Membership Application

Thank you for considering to become a member of CSIH. Membership benefits include reduced rates to the Canadian Conference on Global Health, our online newsletter "Synergy", the opportunity to participate in our Advocacy Committee, our Board of Directors and various Global Health events across Canada

Required fields are marked * Required

CSIH Membership * Required

	Regular - 1 Year
CSIH Regular Membership	$ 50.00
Student/Non-Wage Earner	$ 25.00
Organizational	$ 250.00

Taxes are extra as applicable.

Promo Code

Please enter the promo code if applicable:

Personal Information

First Name * Required Last Name * Required Organization * Required Job Title Industry * Required

Address Information

Address 1 Address 2 City Country Province/State * Required

Postal/Zip Code

Contact Information

Telephone (Use only: [0-9 and -]) Ext Toll-Free Toll-Free Ext Fax (Use only: [0-9 and -]) Cell

Email * Required Confirm Email * Required Website URL Facebook Twitter LinkedIn

CSIH membership emails * Required

I agree to receive CSIH emails, and understand that I can unsubscribe at any time.

I do not wish to receive CSIH emails.

Professional Information

What is your Profession?

This Section to Remain Unanswered and Empty

Alternate Email - Do not answer

Website URL - Do not answer

Security Captcha * Required

Enter the answer to the question in the below text box.

Yes or no, is Montreal east of Ottawa?