ASSOCIATE MEMBERSHIP APPLICATION

ASSOCIATE MEMBERSHIP APPLICATION
PART 1: ASSOCIATE MEMBERSHIP
Company's Legal Name (as registered with WCB):*
Operating Name:
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email:*
WCB Account Number:*
WCB Industry Code:*
Numbers only/ no spaces; Example: 12345
I am currently not insured or registered with WCB
Note: As a member of the above rate code, you are paying a levy to or naturally aligned with a Manitoba Industry Based Safety Program and as such you are entitled to their services. If you would like more information on this please contact us at 204-775-3171 or safety@constructionsafety.ca.
Affiliated Companies (if applicable)
Legal Name(s):
WCB Account Number(s):
WCB Industry Code(s):
Indicate if you are a member of:

The Manitoba Home Builders’ AssociationThe Winnipeg Construction Association
Member Since:
Name:*
Title:*
Signature:*

Clear
Date:*

MonthDayYear
My signature indicates that all the above information is current and accurate.
Part 2: PAYMENT
Associate Membership annual fee: $500 + GST (from July 1 to June 30) * fee is pro-rated if application is received and processed after the month of June.

Payment can be made by cash, cheque, debit or credit card.
Month field
Total based on date only
Member?
Your total in CAD$ (incl. GST)
Choose your payment method*

Credit card (Visa / MC)Cheque/cash (in person only)N/A (member of MHBA or WCA)

The information provided will be used for associate membership application. This information will need to be disclosed to the provincial government to actually award the COR^®/SECOR^® certification. Upon receiving COR^®/SECOR^® certification the company information will be posted to the Construction Safety Association of Manitoba’s website, www.constructionsafety.ca. Except as described herein, we do not sell, rent or otherwise share or disclose your private personally identifiable information to third parties
ALL APPLICATIONS WILL BE SUBJECT TO A QUALIFYING REVIEW AND APPROVAL PROCESS
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