Application Form

Member Information

Member Type

First Name Last Name

Birth Date Country of Citizenship

Email Address

Home Address

Street Address City Province / State

Postal / Zip Code Country Phone

University/Hospital Information

University Name Hospital Name

Permanent Office Information

Street Address City Province / State

Postal / Zip Code Country

Phone Number Fax Number

Training

General Surgery

Location

Start Date End Date

Paediatric General Surgery

Location

Start Date End Date

Certification

Certificate of Special Competence, Royal College of Physicians and Surgeons of Canada, American Board of Surgery or equivalent certifying body (please specify): Yes No

Start Date Certifying Body

Sponsors

Names of 2 Active or International members, one must be/have been a mentor in your training program:

Name Email

Name Email

Please note that only complete applications, including supporting documents from sponsors, will be considered. All applications must be reviewed by the Membership and Credentials Committee and approved by the membership of CAPS at the Annual General Meeting before membership is granted. You will be notified if your application has been approved.