AUTOMATIC MEMBERSHIP REGISTRATION

Company's Legal Name (as registered with WCB): *

Operating Name:

Address *

Street Address

Street Address Line 2

City State / 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’ Association The 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® Certification Consulting Services Hazard Identification Legislation Safe Job Procedure Safety Training Safety and Health Materials

Name: *

Title: *

Signature: *

Clear

Date: *

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.