WCOWMA Corporate Member Application Form

WCOWMA Executive Member Application
Medical Volunteer Information
Organization Name*
Membership Contact Name*
Email (Membership Contact)*
example@example.com
Phone Number (Membership Contact)*
Address (Membership Contact/ Organization)*

Street Address

Street Address Line 2

CityProvince/State

Postal Code/Zip CodeCountry
Business Category*

Supplier-EquipmentSupplier-Services
A WCOWMA Executive Membership inlcudes up to 11 Under Corporate Memberships total, three members per provincial association. After completing the application we will follow-up to discuss who you would like to add to your Under Corporate Membership Allotment.
How would you like to pay for your WCOWMA Executive Membership?

Credit CardE-TransferInvoice
Select your WCOWMA Membership Level !*

WCOWMA Platinum Membership $7,000 CADWCOWMA Gold Membership $5,000 CADWCOWMA Silver Membership $3,000 CADWCOWMA Bronze Membership $1,500 CAD
For Payment via Invoice Our WCOWMA Accounting Administrator will follow-up with instructions. Please continue with the rest of the form and submit!
For Payment Via E-Transfer, please send funds to: accounting@wcowma.com

My Products*

WCOWMA - Platinum Membership

$7,000.00CAD

WCOWMA - Gold Membership

$5,000.00CAD

WCOWMA - Silver Membership

$3,000.00CAD

WCOWMA - Bronze Membership

$1,500.00CAD

Total

$0.00CAD

WCOWMA Executive Member Application