membership application

The membership application form below is designed to gather necessary information for the Membership Committee to review prospective members before ratification by the Board of Directors. Should membership status be granted, this information will be added to the searchable, secure, members’ only, member database. The database can be searched by name or location and is designed to facilitate networking and contacts between CCIC members. Your information will appear in the database exactly as it is input.

Please note that you may return at any time to update the information you provide by selecting the 'Update Member Information' option. You may also choose to complete any non-mandatory questions at a later time, if you do not have time to do so right now.

* are mandatory fields

MEMBER REGISTRATION FORM

1.	Salutation:
2.	First Name:*
3.	Last Name:*
4.	Address:
5.	City:
6.	Province/State:
7.	Postal Code:
8.	Country:*
9.	Telephone:
10.	Fax:
11.	Email:*
	Your email address will become the username that you will use to log on to the CCIC web site. You will also be asked to create a unique password. The CCIC will never sell or share our members’ email addresses with any other organization.
12.	Job title:*
13.	Qualifications:*
14.	Professional Affiliations:*
15.	Organization/Company:
16.	Please describe your interest in cannabinoid research and education. This information will be use to help our membership committee evaluate your application.
17.	Select Membership type:
	Active Member(Canadian MD or PhD) Associate Member (Allied health care professional, Graduate or Post graduate health care student in any related field, Resident, Fellow; Scientist with a research interest relevant to cannabinoid therapeutics in another country; Physician in another country) Emeritus Member (Medical colleague who has retired from active practice or academic work) Observer (Individual with a sustained interest in the mission of the Consortium, but do not qualify for Membership. Examples of Observers may include: pharmaceutical company employees, patients, members of activist groups or interested persons from non-medical backgrounds) An Observer shall not be a member of the consortium thus shall have no vote nor hold office. Observers will be granted access to the Consortium’s online resources through a username and password; they will also be included in the CCIC mailing list and receive newsletters and updates. The Board of Directors retains the authority to redefine or revoke benefits or status of Observers without notice.
18.	Select Application type:
19.	Do you agree to have your information posted in the CCIC’s secure membership database? Your information will only be accessible by CCIC members to facilitate networking between individuals interested in the CCIC. We will never distribute your information to other groups or organizations? * YesNo
20.	Would you like to receive CCIC Newsletters and updates? YesNo
21.	How did you learn about the CCIC? Conference Course or seminar Invitation email Referred by an outside organization Referred by an individual or word of mouth Online search or website Other


User Login To login to the CCIC web site, you will require both a username and a password. Your username will be the email address that you have entered above. Your password is chosen by you.
Password (between 6 and 16 chars):*
Confirm password:*