Standing Committee Membership Application

Standing Committee Member Request/Reaffirmation
I am * representing the Member Organization/Self* , and I First Name & Last Name*formally request * join the * as a *
Representative Appointment
Primary Standing Committee Member
As an Ind./ Des. Rep/ Alt. Rep representing the Member Organization/Self* , I First Name & Last Name* appoint:

First Name & Last Name* Email* Phone Number*
to serve as the Primary Standing Committe Member on the Standing Committee.
Will your member organization be appointing an Alternate Standing Committee Member to serve on the committee?*

YesNo
Alternate Standing Committee Member
As   Ind./Des. Rep/Alt. Des. Rep.   , of the Member Organization,  I First Name & Last Name appoint:

First Name & Last Name  Email Phone Number
to serve as the Alternate Standing Committee Member on the Standing Committee.
Authorized Signatory*

Clear
Applications for membership to the standing committees are reviewed and approved by Actsafe's Board of Directors.

Once your application has been processed, you will receive a confirmation email from Actsafe. If you have any questions, please contact Actsafe at 6047334682 or info@actsafe.ca.
Should be Empty:

Standing Committee Member Request/Reaffirmation