Membership Application Form

BANGLADESH MEDICAL SOCIETY OF ALBERTA

(BMSA)

First Name

Last Name

Medical Degree:

Graduation Year:

Institute name:

Country:

Postgraduate Degree:

Graduation Year:

Institute name:

Country:

Expertise and/or Special Interest (Professional and Extra-professional):

Membership/Fellowship (with professional body/society/association):

Volunteer experiences:

Mailing address:

City:

Postal Code:

Email Address:

Phone Number:

Membership Type:

General membership ($10/year) Lifetime membership: ($150) Associate (no fee)

Please read terms of Bylaw and select checkbox to accept terms:

I do, hereby, declare that I am a Bangladeshi (by birth, domicile or descendant); a medical graduate; and a resident of Alberta, Canada. I assure that I shall abide by the bylaws. Further, I certify that all information submitted on this form is true, accurate and complete, and if found otherwise, I will be legally liable. I do, hereby, give consent to the the collection, use or disclosure of my personal information [in compliance with the Section: 36(1) to (3) and Section: 36.1(1) to (3) of the Societies Act of Alberta; the Section: 8(1) of the Personal Information Protection Act of Alberta; and any other related act] submitted on this form.

Please upload your photo: