User account | Caribbean Cardiac Society

Account information

Username: *

Your preferred username; punctuation is not allowed except for periods, hyphens, and underscores.

E-mail address: *

A valid e-mail address. All e-mails from the system will be sent to this address. The e-mail address is not made public and will only be used if you wish to receive a new password or wish to receive certain news or notifications by e-mail.

Confirm e-mail address: *

Please re-type your e-mail address to confirm it is accurate.

Password: *

Confirm password: *

Provide a password for the new account in both fields.

Account Information

Phone Number: *

Private Address: *

The content of this field is kept private and will not be shown publicly.

Business Address: *

The address for your place of business or practice.

Nationality: *

Account Type

I wish to apply for membership the Caribbean Cardiac Society in the category of : : *

Declaration

I Agree to the applicant's declaration stated below.

I declare that the information given on this application is correct. I agree to be bound by the constitution and to observe the Rules, Regulations and By-Laws of the Society. I agree to pay the annual subscription applicable to the grade membership into which I am admitted immediately I am advised that my application is accepted. I agree to pay an application fee of US$50.00 for regular Member or US$10.00 Associate Member at a later date. I additionally agree to the rules of membership as stated HERE

Employment Information

Current Employment: *

Please state your current employer/practice and your position.

Date Commenced at Current Employer:

Additional Information: *

Applicants are invited to provide additional information regarding experience relevant to their medical career. This information might include awards, publications, lectureships and/or further details of work experience. Applications also attach a copy of their C.V.

Professional Work Experience: *

Please state your professional work experience prior to being at your current position

Nomination

Name and Status of two persons nominating you: *

Personal Information

Sex: *

Date of Birth: *

Educational Background: *

Please state your educational background including: Institutions attended, years you attended and qualifications gained

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions.

Math Question: * 5 + 4 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.