College of Family Physicians of Canada

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College of Family Physicians of Canada Registration Form

* Indicates Required Field / Question

Participant ID *

Old Participant ID

Salutation

First Name *

Last Name *

Sex

Mail Language

Address 01

Address 02

Address 03

City

Province

Province Description

Postal Code

Country Code

Country Description

Email

Location Code

Birthdate

Profession *

Class *

Class Effective Date

Designation

Chapter

Chapter Name

Member Status

Discontinued Flag

Discontinued Reason

Discontinued Reason Description

Discontinued Date

Enrollment Date *

Reinstatement Flag

Reinstatement Date

US or Foreign Flag

MINC

Primary License Province/Territory

Other License(s) Province/Territory

Mobile Phone Number

Office Phone Number