Alberta Medical Laboratory Technologists Insurance Application

Applicant Information

First Name *

Last Name *

Street Address *

Address Line 2

City *

Province *

Postal Code *

Phone Number *

Email Address: *

Confirm email address: *

Member Registration Number: *

Birth Date * +

Are you currently in good standing with the College of Medical Laboratory Technologists of Alberta or in the process of registering for the CMLTA? *

Yes

Policy Effective Date:
All policies under this program will run from effective date until January 1 2025 * 🛈 +

Are you self-employed? *

Yes