HEALTH RESEARCH NETWORK MEMBERSHIP APPLICATION FOMR

The Population & Community Health Unit

Name: __________________________________________

Department: ______________________________

Faculty/Organization: _________________________________

Address: ______________________________________

City: _____________________________

Postal Code: ______________

Telephone: ________________________       Fax: ________________________

Email: _________________________

Research/Interests: ___________________________________________________

___________________________________________________________________

___________________________________________________________________

Methodologies / Statistical Skills and Expertise:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Please return form to:

The Population & Community Health Unit,
Family Medicine,
Schulich School of Medicine & Dentistry, 2nd Floor,
London, Ontario, Canada
N6A 5C1
Fax: (519) 858-5063