Ontario Homeopathic Association

ONTARIO HOMEOPATHIC ASSOCIATION

1043 Bloor Street West, Suite 205, Toronto, Ontario, Canada M6H 1M4

STUDENT MEMBERSHIP APPLICATION

(For students from health related schools)

NAME:

ADDRESS:
CITY: 
PROVINCE:

POSTAL CODE:
TEL:  
FAX:

E-MAIL:

Educational Institution

Program

Degree/Diploma/Certificate

Graduation Date

       
       
       


Please find enclosed the following:


  Proof of enrolment/student registration

  $50.00 (CDN) for annual dues



Note: An application package will be reviewed once all the above have been submitted.


 

 
Signature                                                                                   Date:
 

 

 FOR OFFICE USE ONLY

 Comments:

 Date:

    APPROVED                   DENIED  

 Registration No.: