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MSA Membership Form
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MSA Membership Form
Personal Information
Are you currently medical staff at Langley Memorial Hospital?
(Required)
Yes
No
Name
First
Last
Address
(Required)
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
MSP Number
(Required)
Preferred Email Address
(Required)
Mobile Number
Position
General Practitioner
Specialist
Nurse Practitioner
Midwife
Status
Active
Associate
Locum
Provisional
Department
Membership Type
Membership Due - $155 (A $5 convenience fees is included in the dues)
Price:
Total
Membership Agreement
(Required)
I agree to become a member of the LMHMedical Staff Association and abide by its bylaws and MSA staff rules
I consent to be contacted occasionally via email to be informed about events, opportunities and services provided by the LMH Medical Staff Association and the LMH Physician Association
I consent to using my photographs/videos taken at MSA/LMHPA sponsored on the website
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Contact Us
22051 Fraser Hwy, Langley City, BC V3A 4H4
info@msalmh.ca
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