CIP Membership Form

Which Provincial and Territorial Institute or Association (PTIA) do you currently hold membership with?:
What type of CIP membership are you applying for?:
Have you previously held CIP Membership?:
What date did you become a Provisional/Candidate member of your PTIA?:
What date did you become a Full member of your PTIA? (If applicable):
CIP Clauses:
I certify that I am a member in good standing of my PTIA:
I certify that CIP can send me email as required. Review the CIP privacy policy (see link above):
I certify that the information I have provided on this form is correct, and that I am eligible for the membership category for which I am applying:
Organization/Employer:
Please provide the following details:
Honourific:
First name:
Middle Name:
Last name:
Mailing Address:
City/Town:
Province / Territory:
Postal Code:
Email:
This will be your login email address. Confirm email:
Birthdate:
Gender:	MaleFemale
Telephone:
Alternate Phone (Cell/Work):
Display in Find a Member?:	YesNo
Accept 3rd Party Mail?:	YesNo

Address:	Adresse :	141 Laurier Avenue West, Suite 1112 Ottawa ON K1P 5J3	141, avenue Laurier ouest, Bureau 1112 Ottawa (Ontario) K1P 5J3
Telephone number:	Tél :	800.207.2138 or 613.237.7526 (PLAN)	800.207.2138 ou 613.237.7526 (PLAN)