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APPLICATION FOR 2010 'RESEARCH ASSOCIATE' FELLOWSHIP I hereby apply for election to Fellowship in
the Occidental Institute Research Foundation (OIRF), as a Research
Associate, under the statutes of that international nonprofit incorporated
Society for practitioners of Biological Medicine. Enclosed, are my initiation
and membership fees of CDN $75 for the calendar year of 2010. Signature _____________________________________ Date_____________ Name (Print) ____________________________________________________ Degree(s) ___________________ Licensed As_________________________ Address ________________________________________________________ City ____________________State/Prov. _____________ Country _________ Zip/Postal Code ___________ Phone Numbers ________________________ Fax Number ________________ E-Mail Address_______________________ /___/ To receive your announcements and "The Bridge" newsletters by Postal Mail add CDN $50 My specific areas of interest in the field of Biological Medicine are: _______________________________________________________ Payment method: I am paying my 2010 initiation/membership fees totaling CDN $75 by the following means: /___/ Check or Money Order Enclosed /___/ Visa /___/ MasterCard Credit Card Number ____________________________________________________ Your name as it appears on the credit card _________________________________ Signature ___________________________ Expiry
Month/Year ___________ If paying by credit card, you can FAX this form to (250) 490-3348 in Canada. Send check/money order to: For additional information phone (800) 663-8342
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