P.M.C.Q. Membership Application Form 2011 / 2012 Season: September 1, 2011 - June 30, 2012
Simply complete and return this form or bring this completed form with you to our next meeting.
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:
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 the speakers agenda?
Invoicing 2011 / 2012 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) + 9.5% QST ($24.94)]
Annual Privileged Membership (per person, including membership and monthly dinner fees)
$574.88 = $500.00 + taxes [5% GST ($25.00) + 9.5% 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:
