Application

The application form below is designed to gather necessary information for the Applicant Review Committee to review prospective members before ratification by the Board of Directors. Should your application be approved, this information will be added to the searchable secure CCIC only database. The database can be searched by name or location and is designed to facilitate networking and contacts within the CCIC. Your information will appear in the database exactly as it is input. Please note that you may return at any time to update the information you provide by selecting the 'Update Information' option. You may also choose to complete any non-mandatory questions at a later time, if you do not have time to do so right now.

* are mandatory fields

REGISTRATION FORM

1. Salutation:
2. First Name:*
3. Last Name:*
4. Address:
5. City:
6. Province/State:
7. Postal Code:
8. Country:*
9. Telephone:
10. Fax:
11. Email:*
  Your email address will become the username that you will use to log on to the CCIC web site. You will also be asked to create a unique password. The CCIC will never sell or share your email addresses with any other organization.
 
12. Job title:*
13. Qualifications:*
14. Professional Affiliations:*
15. Organization/Company:
16. Please describe your interest in cannabinoid research and education. This information will be use to help our review committee evaluate your application.
17. Select Application Category:
(see category descriptions below)
  Member - Membership in the Consortium shall be available to: Licensed Active Canadian Physicians, Nurse Practitioners, Pharmacists; Researchers (PhD) affiliated with a Canadian University or recognized institution.

Supporter: Associate - Allied health care professionals not qualifying for Membership; Scientists with a research interest relevant to cannabinoid therapeutics; Non-practicing physicians; and Physicians practicing outside of Canada.

Supporter: Trainee Associate - Undergraduate, Graduate (Masters or PhD), Post-Doctoral Trainees in any related field of study or research; Residents and Fellows.

Supporter: Observer - Observer status shall be accorded to individuals who have demonstrated a sustained interest in the mission of the Consortium, but who do not qualify for Membership or as non-member Associates. Examples of Observers may include: pharmaceutical company employees, trainees in unrelated fields of study, patients, members of activist groups or interested persons from non-medical backgrounds.

18. Are you new to the CCIC, or is this a renewal?
19. Do you agree to have your information posted in the CCIC’s secure database? Your information will only be accessible within the CCIC network to facilitate networking between individuals interested in the CCIC.*
YesNo
20. Do you agree to belong to the CCIC mailing list.  Belonging to the CCIC mailing list will enable you to receive Newsletters, Newsflashes, CCIC promotional materials and other updates.  You will be able to withdraw your consent at any time.*
YesNo
21. How did you learn about the CCIC?
Conference
Course or seminar
Invitation email
Referred by an outside organization
Referred by an individual or word of mouth
Online search or website
Other


User Login (Forum)
To login to the CCIC web site forum, you will require both a username and a password. Your username will be the email address that you have entered above. Your password is chosen by you.
Password (between 6 and 16 chars):*  
Confirm password:*