Submit your application
Application to become a CIAC Regular Member
Full Name:
*
First Name
Last Name
Home/mailing Address:
*
Street Address
Street Address Line 2
City
Province
Postal Code
Phone:
*
-
Area Code
Phone Number
E-mail:
*
Pronouns:
*
He/Him
She/Her
They/Them
CIAC Member Number
*
Received when you signed up for Associate Membership; required for approval of Regular Membership
Are/were you law enforcement or other first responder?
*
Yes
No
Are/were you a CAN-BIKE Instructor?
*
Yes, current/active Instructor
Yes, current/active Master Instructor
Yes, current/active National Examiner
Yes, previously certified (lapsed)
No
What is your desired level?
*
Instructor Level 1
Instructor Level 2
Instructor Level 3
Instructor Level 4
Course Conductor Level 1
Course Conductor Level 2
Course Conductor Level 3
Course Conductor Level 4
Teach Kids
Teach Adults
Why do you want to become a CIAC member?
*
Cycling CV or resume:
*
Upload your cycling CV and/or resume
Anything else to add to your application?
Submit Form
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform