AUTOMATIC MEMBERSHIP REGISTRATION

AUTOMATIC MEMBERSHIP REGISTRATION
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:*
This industry code does not belong to Construction Safety Association of Manitoba's Automatic Membership. Please make sure that your code is 5 digits only (no spaces and no special characters).

To register as an Associate Member, please use this form instead.
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
Please give us a brief description of the type of work your company conducts:
Please indicate which CSAM services your company would like more information on (select all that apply):

COR® CertificationConsulting ServicesHazard IdentificationLegislationSafe Job ProcedureSafety TrainingSafety and Health MaterialsOther
Name:*
Title:*
Signature:*

Clear
Date:*

MonthDayYear
My signature indicates that all the above information is current and accurate.
The information provided will be used for automatic membership registration. 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.
Should be Empty: