P.M.C.Q. Membership Application Form 2019 / 2020
Season: September 1, 2019 - June 30, 2020

All fields marked with a * are required

*Name:

Title:

*Company:

*Address:

*City:

*Postal Code:

*Province:

*Tel.:

Fax:

*E-mail:

If you would prefer to receive meeting notices at a different address, please indicate address below:

Address:

City:

Postal Code:

Province:

Occasionally the PMCQ mailing list is made available to organizations for subjects of interest to our members. If you do not wish to receive such information, check here.

Please indicate your industry classification:

Pharma Company     BioTech     Advertising Agency     Media     CHE / CME

Other:

What are your suggestions for educational content for future meetings?

Invoicing 2019 / 2020 PMCQ Membership

Return with payment to:

CMPQ/PMCQ
CP/PO Box 813, 15 avenue Donegani
Pointe-Claire-Dorval (Québec) H9R 4Z5
Tel : (514) 486-3458
Fax : (514) 486-4794

Annual Regular Membership (per person)

$287.44 = $250.00 + taxes [5% GST ($12.50) + 9.975% QST ($24.94)]

Annual Privileged Membership (per person, including membership and monthly dinner fees)

$574.88 = $500.00 + taxes [5% GST ($25.00) + 9.975% QST ($49.88)]

G.S.T.: 101019735
Q.S.T.: 1002033794

*Payment by:

Cheque     Visa     Mastercard     American Express

Card #:

Expiry Date:

Cardholder's Name:

Signature:

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