Affiliate Membership Application Form
Individual
This application form is for Affiliate Membership ONLY.
Affiliate-Individual
- Individuals who share an interest in the goals, role, function and objectives of PACCP but do not qualify for Association or Certified membership.
Please fill out the below information to submit your membership application to PACCP.
Class Applying For:
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Individual
Name of Individual Applying
*
MAILING ADDRESS
Street/Box Number
*
City/Town
*
Province
*
Postal Code
*
Phone Number (Daytime)
*
Phone Number (Evening)
Phone Number (Cell)
Email Address
*
How did you find out about PACCP?
Graduate School
Website Search
PACCP Member
Colleague
Other
INFORMATION
Please provide us a summary of why you would like Affiliate membership with PACCP and what you are hoping to see this affiliation evolve into.
Summary as stated above
MEMBERSHIP AGREEMENT
I have read and understand the following and am in agreement (Please check):
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PACCP Statement of Beliefs
Signed
*
Date
*
-
Month
-
Day
Year
Date
Payment Details: Once application has been reviewed, an electronic invoice will be sent with membership fee payment by credit card.
*
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Application Fee (One Time)
$
50.00
CAD
Every Application for membership is required to submit a one time Application Fee. This is non-refundable
Total
$
0.00
CAD
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit Application & Payment Now
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