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MEMBER APPLICATION FORM 

Please complete the form as best you can, and tick √ all that apply to you.
First Name Last Name I am applying as a Type of Membership I would like (for Affiliate/Organization Members) Organization Name Organization Contact Name Position in Organization Mailing/Street Address Apt No. City Province/Territory Postal Code E-mail
No Email
Landline Cell I would like to receive all written communications by
I am on
Facebook
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Other
Have you been formally diagnosed with FM? If yes, what year?
What, if any, other chronic illnesses do you have?
Myalgic Encephalomyelitis/Chronic Fatigue Syndrome
Multiple Chemical Sensitivity/Environmental Sensitivities
Chronic Pain
Sleep Disorders
Diabetes
Irritable Bowel Syndrome
Gastroesophageal Reflux Disease (GERD)
Peripheral Neuropathy
Costochondritis
Other type(s) of chronic illness not listed above
I do not have a chronic illness
I am currently
on disability benefits
unemployed
medically retired
a senior/elder
a student
working full-time
working part-time
working casual
other
My professional qualifications My skills I am interested in volunteering with this organization
If YES, which Committees/work are you interested in?
Steering Council
Awareness Standing Committee
Research Standing Committee
Education Standing Committee
Advocacy Standing Committee
Regional Representative
Accounting
Administration
Fundraising
Grant Writing
Human Resources
Marketing
Public Speaking
Website Development/Management
Payment of $
for
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