SEIPS Membership Application

Testing has indicated this form should take no longer than 5 minutes to complete.

Demographics

Credentials: *

Membership designation: *

Gender: *

Male

Female

First name: *

Last name: *

Position/Title: *

Employer name:

Contact information

Primary address: *

Address: *

City/State/Zip: *

Province/Postal Code/Country: *

Phone:

Fax:

Email: *

Would you like to receive email notifications of Patient Safety Seminars?: *

Yes

Have you attended the SEIPS Short Course?: *

Yes

If you have a personal website please add the URL below. The next two pages are optional for you to complete. If you do not have a website, please complete the next two pages to give us a better idea of your interests. Thank you.

Your website URL:

Last updated 11-25-2008

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