Membership Application Subscription Personal Info - Saskatchewan Association of Combined Laboratory & X-ray Technicians

Membership Application Personal Info

Ensure that all fields with the red asterisk (*) are filled in.

Please enter your names and home address below

First Name *

Last Name *

Address

Address Line 1 *

Address Line 2

City *

Country *

Province/State *

Province/State

Postal/Zip *

Birthday

Please indicate your contact information below

Primary Email *

Secondary E-Mail

Phone *

Cell Phone

Separator - Employment

Current Work Status *

Enter in information about your primary employer, if you have one.

Employer Name

Number of Facilities Worked

Employer Address

Address Line 1

Address Line 2

City

Country

Province/State

Postal/Zip

Work Phone

Ext.

Primary Work Fax

Date Employed

Username *

Password *

Password Confirmation *