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)
Format: (000) 000-0000.
Address (Membership Contact/ Organization)

Street Address

Street Address Line 2

CityProvince/State

Postal Code/Zip CodeCountry
Business Category
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?
Select your WCOWMA Membership Level !
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

WCOWMA - Platinum Membership

$7,000.00 CAD

WCOWMA - Gold Membership

$5,000.00 CAD

WCOWMA - Silver Membership

$3,000.00 CAD

WCOWMA - Bronze Membership

$1,500.00 CAD

Total

Billing Contact Name

First NameLast Name
Billing Contact Email
example@example.com
Billing Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Signature
Should be Empty:

WCOWMA Executive Member Application