Application for Company Affiliation

Application for Company Affiliation

NOTE: This form is to be completed to register an affiliated company to another CSAM registered company. The affiliated company must have the same ownership / management group and separate WCB account number.
Current Company's Legal Name (as registered with WCB):
WCB Account Number:
WCB Industry Code:
Phone Number
Format: (000) 000-0000.
Email:
Is the current company COR® or SECOR® Certified?
Would you like to have the subsidiary company COR® or SECOR® Certified as well?
NEW Affiliated Company Name (as registered with WCB):
WCB Account Number:
WCB Industry Code:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email:
Contact Person:
Title:
Signature:
Date:

MonthDayYear
My signature indicates that all the above information is current and accurate.
All applications will be subject to a qualifying review and approval process.
Should be Empty: