CAPM :: Canadian Academy of Pain Management

This application is for joint membership with the Canadian Academy of Pain Management and the American Academy of Pain Management. Discounted annual fees are applicable for joint members. Please visit the AAPM website to apply for membership with that organization."

Already a member of AAPM
Already a diplomate of AAPM

Title:
First Name:
Middle Initial:
Last Name:

Mailing Address:

City:
Province:
Postal Code:

Phone Work:
Phone Home:

Fax:
E-Mail:
Website:

Academic Degrees:

Hospital Affiliation:
Private Practice?	Yes No

Academic Appointment:

Please Choose from the following:

Physician

Physiotherapist

Registered Nurse

Psychologist

Occupational Therapist

Dental Surgeon

Pharmacologist

Social Worker

Chiropractor

Other:

Physician Members in Practice	$190
Active Members, non-physicians	$100
Students/members in training	$25

I hearby allow the above information to be published online on the CAPM website.

Payable To:

Canadian Academy of Pain Management
5734 Yonge Street, Suite 300
Toronto, ON.
M2M 4E7

www.aapainmanage.org
www.canadianpainsociety.ca
www.iasp-pain.org