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2010
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Membership Application Form
Please fill out the following application form.
Fields with asterisks (
*
) are required.
General Email (Username):
Display Email Address in Directory
*
Password:
(Enter the password you would like to use to enter the Members Only area.)
*
Company:
Legal Company Name:
*
Business Address:
*
City:
*
Province:
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Other Province
*
Postal Code:
*
Country:
Canada
Other Country:
Has Different Mailing Address
Mailing Address:
City:
Province:
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Other Province:
Postal Code:
Country:
Canada
Other Country:
*
Business Phone:
Preferred Format: (604) 123-4567
Secondary Phone:
Toll-Free:
Fax Number:
Display Fax Number in Directory
Can Fax at Night
Display Website1 Address in Directory
Website1:
Website2:
Preferred Information Broadcast Method:
Email
Fax
Mail
Home Based Business
*
Business Types:
Corporation
None
Partnership
Proprietorship
Business Categories:
Membership Type
Rate
Admin Fee
Total GST
Total
Standard
190.00
23.00
10.65
223.65
2nd Business
125.00
23.00
7.40
155.40
Not For Profit
125.00
23.00
7.40
155.40
Membership Fee Charged:
$0.00
If Membership Type is 2nd Business, please provide the name of the parent company
Other Fee Charged:
$0.00
Total Fee Charged:
$0.00
Company Logo:
*
Brief Business Desc:
*
Detailed Business Desc:
Reason For Joining:
Referred By:
Contact Information
*
Title:
Salutation:
Dr
Mr
Mrs
Ms
*
First Name:
*
Last Name:
Primary Email:
Secondary Email:
*
Direct Phone Line:
Cell Phone:
Fax:
Home Phone:
Pager Number:
Primary Contact:
Preferred Contact Method:
Email
Fax
Mail
Payment Information
Payment Method:
Amex
MasterCard
Visa
Card Number:
Name On Card:
Expiry Date:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
2008
2009
2010
2011
2012
2013
*
Title:
Salutation:
Dr
Mr
Mrs
Ms
*
First Name:
*
Last Name:
Primary Email:
Secondary Email:
*
Direct Phone Line:
Cell Phone:
Fax:
Home Phone:
Pager Number:
Primary Contact:
Preferred Contact Method:
Email
Fax
Mail
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