Winnipeg Chapter Society for Neuroscience

2016 Membership Application and Renewal Form



 

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Membership Benefits
Current Members


* = Required Fields.

    Please fill in this form and click on the "Send" button below.
Name:*
Position Title:
Telephone:*
E-mail:*
Organization/
Department:*
Mailing Address:*
URL:
Note: Please copy the Web-address of your current 'Professional Profile'
web page in your web browser and paste it here.
If you are a trainee,
please complete:
Name of Supervisor:
Department Affiliation:
Program:
MSc PhD PDF
Category of
Membership:*
Note: Membership fees are for the calendar year (January-December).
Faculty, Professionals
  $60.00 CAD
Postdocs, Residents, Technicians, Research Associates   $30.00 CAD
Students   $15.00 CAD
All-inclusive Lab Rate
(enter member names below and name of supervisor above)
$100.00 CAD
Laboratory Supervisor: (for all-inclusive lab rate)
Laboratory Members: For all-inclusive lab rate, enter one lab member per line, as:
first and last name / position / e-mail address
Enter ALL information for each person please!
Membership Number:
 For renewals, please provide your membership ID number, e.g. RC-XXX.
Payment Method:*
Select one of the following payment methods:
Secure Credit Card Payment (Visa/Mastercard only)
Cheque *
      * Please make cheque payable to:
          St. Boniface Hospital, c/o Winnipeg Chapter Society for Neuroscience
      and send to:
          Winnipeg Chapter Society for Neuroscience
          R4046 - 351 Tache Ave., Winnipeg, MB R2H 2A6, Canada
FOAP     Enter U of M FOAP #: - - -
Pre-paid Lab (new member of lab that already paid all-inclusive lab rate)