Membership Application...

Please Complete the Membership Application Form below.

Membership dues will be assessed by the Board of Directors upon       development of a comprehensive strategy and launch of services.        Until that time, there is no charge for this Special Interim Membership to ACT Canada.        All members will be notified in advance when the Board establishes a dues       structure and may withdraw their membership at any time.  Note that this Special Interim Membership does not provide for voting privileges.

1. I understand that my completion of this form is an application for membership on behalf of the corporation/municipality/organization I am authorized to represent.

I understand and agree with the above statement

2. I understand that   this is a Special Interim Membership which is intended to permit the evolution   of ACT Canada only. When services are launched and provided to members, a dues   structure will be implemented for various membership classes.

  I understand and agree with the above statement

  I understand and agree with the above statement

Your Name
Organization Name
Job Title
Address 1
Address 2
City
Province/State	(Click here to choose)  Alberta  British Columbia  Manitoba  New Brunswick  Newfoundland  Northwest Territories  Nova Scotia  Nunavut  Ontario  Prince Edward Island  Quebec  Saskatchewan  Yukon  Alabama  Alaska  American Samoa  Arizona  Arkansas  California  Canal Zone  Colorado  Connecticut  Delaware  District of Columbia  Florida  Georgia  Guam  Hawaii  Idaho  Illinois  Indiana  Iowa  Kansas  Kentucky  Louisiana  Maine  Maryland  Massachusetts  Michigan  Minnesota  Mississippi  Missouri  Montana  Nebraska  Nevada  New Hampshire  New Jersey  New Mexico  New York  North Carolina  North Dakota  Northern Mariana Is  Ohio  Oklahoma  Oregon  Pennsylvania  Puerto Rico  Rhode Island  South Carolina  South Dakota  Tennessee  Texas  Trust Territories  Utah  Vermont  Virgin Islands  Virginia  Washington  West Virginia  Wisconsin  Wyoming
Postal/Zip Code
Business Phone #
Business Fax #
E-mail
Name of Secondary Contact (if     applicable)
Title of Secondary Contact (if     applicable)
Phone of Secondary Contact (if     applicable)
E-mail of Secondary Contact (if     applicable)

5. Comments/Questions:

 

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