Professional Interest Application 20110301

							         Department of Epidemiology, Biostatistics and Occupational Health

                                                      SUMMER SESSION 2011 APPLICATION FORM
                                      Professional Interest Certification or Continuing Medical Education (CME) Credits
Instructions
                                                                                 I am interested in applying for
  1. Please type or print clearly and fax this form to the Graduate Studies
     Office at 514-398-8851.                                                            Professional Interest Certification
                                                                                        CME Credits:      MEDICAL LICENSE #:
  2. Send a short CV and the registration fee of $100 CAD (non-refundable)
     payable to McGill University by money order/bank draft drawn on                                      ISSUING PROV./COUNTRY:
     Canadian of US bank. You can also pay by Visa or Master Card.
                                                                                 COURSE #            CREDITS    TITLE
  3. The $100 registration fee will be applied towards the total fee according
                                                                         rd      EPIB
     to your final course selection. The balance of fees is due by the 3
     lecture day at the Student Affairs Office, Purvis Hall room 27.
                                                                                 EPIB


                                                                                 EPIB
TITLE:             Mr.       Ms.      Mrs.       Dr.
                                                                                 EPIB

FAMILY NAME:
                                                                                 EPIB

GIVEN NAME:
                                                                                 Cost: $550 per credit for the first 6 credits, and $250 per each subsequent credit.
                                                                                       (e.g.: cost for 2 credits = $1,100; cost for 7 credits = $3,550)

NATIONALITY:       Canada            province:                                   TOTAL FEES DUE:                      $

                   International     country:                                    LESS REGISTRATION FEE:         -     $ 100.00 (non refundable)

                                                                                 BALANCE DUE:                   = $
COMPANY:                                                                         APPLICANT
                                                                                                                                            DATE:
                                                                                 SIGNATURE
ADDRESS:                                                      APT./SUITE:
                                                                                 Method of payment:            Visa       Master Card      Bank Draft/Money Order
CITY:                                        PROV./STATE:
                                                                                 To pay by credit card, complete and sign the authorization below.
COUNTRY:                                     POSTAL CODE:                        Please charge the following to my credit card:    Registration Fee    Total Fees Due

DAY PHONE:                                   OTHER PHONE:                        NAME OF CARD HOLDER:


                                                                                 CARD NUMBER:                                               EXPIRY DATE:
EMAIL:

                                                                                 CARD HOLDER
                                                                                                                                            DATE:
                                                                                 SIGNATURE



                                                                                                                                               Last update: 01 March 2011