CAHD-ACDH The national voice of Canadian hospital-affiliated dentists cahd@cahd-acdh.ca

Renew membership

Membership renewal membership

Renew membership

Membership Renewal form

Renewal Information

Dr.

To update/correct membership information, please make the necessary edits below.


1. Application Information

Name:

Date of birth:

Citizenship:

2. Address Information

Primary Office Address


Province/State:

Country:

Office Phone: Office Fax:

Home Address


Province/State:

Country:

Home Phone: Cell:


Preferred mailing address:OfficeHome

3. Hospital and university appointments

Are you a GP or specialist?GPSpecialist (specify)

Have you completed a GPRAEGD Where?

Present Hospital Appointments:

Hospital name:
Staff position:
Date of appointment:

Hospital name:
Staff position:
Date of appointment:

Present Academic Appointments:

Name of Faculty:
Position:
Date of appointment:

Name of Faculty:
Position:
Date of appointment:

I consent to have my name, position, affiliation and contact information included in a Membership Directory, available to members only, on a secure members page:
YesNo

May we correspond with you via email exclusively? YesNo

Students/Residents Renewal form

Renewal Information for Students & Residents

Dr.

To update/correct membership information, please make the necessary edits below.
No editsYes, there are edits (see below)


1. Application Information

Name:

Date of birth:

Citizenship:

2. Address Information

Primary Office Address


Province/State:

Country:

Office Phone: Office Fax:

Home Address


Province/State:

Country:

Home Phone: Cell:


Preferred mailing address:OfficeHome
May we correspond with you via email exclusively? YesNo

3. Hospital and university appointments

Current Program (check all that apply):

Dental student: Dental Student Year:

Resident: GPRSpecialty program

Graduate Studies: MScPhDOther

University: Date of appointment"



I consent to have my name, position/affiliation and contact information included in a Membership Directory, available to members only, on a secure members page: YesNo

May we correspond with you via email exclusively? YesNo