CCHL / CCLS - The Canadian College of Health Leaders Active Membership Application Subscription Personal Info

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Title

First Name *

Middle Name

Last Name *

Date of Birth *

Gender

Home Address

Address Line 1

Address Line 2

City

Country

Province/State

Postal/Zip

Home Phone

Cell

Photo

Choose file

Please provide us with a professional high resolution photo.

Organization Information

Organization

If your organization is not in the list, please provide a name and address below.

New Organization

Employment Category (please indicate the most appropriate)

Position

Work Address

Address Line 1

Address Line 2

City

Country

Province/State

Postal/Zip

Work Phone

Work Phone Ext

Work Fax

Work Email

The single best description of my organization: (select one)

International Phone Number

Primary Email

Primary email is the email that CCHL will use for correspondence with you.

Secondary Email

Renewal Email

Administrative Assistant

Preferences

Would you like to be included in the members on-the-move list?

Yes No

Language of Preference

Education Information

Education

(if you chose Other Certificate/Diploma for education you may supply the diploma received here)

Diploma

Institution

Year Awarded

How did you learn about the College? (please check only one)

Main reason for joining the College (please check only one)

I am willing to make my resume available to potential employers

Yes No

What areas of the College would you like to be involved? (Please check all that apply)

I have experience in and am able to provide guidance on

Expertise Required/Topics of Interest

Dietary requirements / food allergies

Your dues are paid by

Students must provide copy of proof of enrollment

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Updating your Login Information

You may create or change your user name and password by entering a new username and password below.
Your user name and password must be system unique and must be at least 6 characters long and cannot begin with a space.
Your password should be a minimum of 6 characters and must contain letters, numbers and symbols. We recommend that you avoid using any part of your user name in your password.

Applications received as of September 1st of any year will be valid until December 31 of the following year.

Login Information

Username *

Password *

Password Confirmation *

Membership Interval:

01/01/2019 - 01/01/2020, Active as of this Date: 03/20/2019