PMCQ | Membership Application Form

Simply complete and return this form or bring this completed form with you to our next meeting.

Name:

Title:

Company:

Address:

City:

Postal Code:

Province:

Tel.:

Fax:

E-mail:

If you would prefer to receive meeting notices at a different address, please indicate address below:

Address:

City:

Postal Code:

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Occasionally the PMCQ mailing list is made available to organizations for subjects of interest to our members. If you do not wish to receive such information, check here.

Please indicate your industry classification:

Pharma Company

BioTech

Advertising Agency

Media

CHE / CME

Other

What are your suggestions for the speakers agenda?

Invoicing 2010 / 2011 PMCQ Membership

Return with payment to:

CMPQ/PMCQ
CP/PO Box 813, 15 avenue Donegani
Pointe-Claire-Dorval (Québec) H9R 4Z5
Tél : (514) 486-3458
Fax : (514) 486-4794

Annual Regular Membership (per person)

$282.19 = $250.00 + taxes [5% GST ($12.50) + 7.5% QST ($19.69)]

Annual Privileged Membership
(per person, including membership and monthly dinner fees)

$756.26 = $670.00 + taxes [5% GST ($33.50 GST) + 7.5% QST $52.76 PST)]

Payment by:
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Card #:
Expiry Date:
Cardholder's Name:
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