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_______________________

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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

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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:
                   Occidental Institute Research Foundation (OIRF),
                   P. O. Box 100, Penticton, B.C. V2A 6J9 CANADA

For additional information phone (800) 663-8342 toll free in North America,
                   Or (250) 490-3318 in Canada on weekdays, 8:30 AM to 4:30 PM Pacific Time.