Student Membership Registration Form by Yearoveryear

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									               Student Membership Registration Form

                              Manitoba Society of
                        Medical Laboratory Technologists
                                 585 London Street
                                Winnipeg, Manitoba
                                    R2K 2Z6
                                  Fax: 667-1747
Name:

Mailing Address:


Phone:
E-mail:
Program of Studies ‫ ٱ‬Medical Laboratory Science
                        ‫ ٱ‬Diagnostic Cytology
                        ‫ ٱ‬Clinical Genetics
Year of program enrolled: ‫ ٱ‬Year 1
                                ‫ ٱ‬Year 2
                                ‫ ٱ‬Degree Completion Year
Previous post-secondary education:
 ‫ 42 ٱ‬credits specified by RRC
 ‫ 1 ٱ‬full year of University
 ‫ ٱ‬More than 1 full year, but less then 3 years
 ‫ ٱ‬Undergraduate degree in _____________
 ‫ ٱ‬Post-graduate degree in _____________



      Membership Fee for 2005-07 – No charge
Received by Treasurer:
Date:
Accepted by President:

Expiry Date: December 31, 2007

								
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