Corporate Membership Application

Fri, 2010/07/23 - 9:10am — Guy

Organization Information

Organization Name: *

Street Address: *

Addt'l Address 1:

Addt'l Address 2:

City: *

Postal Code: *

Province: *

Email Address (Primary): *

Phone (Primary): *

Website:

Applicant Information

First Name of Applicant: *

Last Name of Applicant: *

Job Title of Applicant: *

Email Address of Applicant: *

Phone (Primary): *

Street Address (Primary):

City (Primary) :

Province:

Postal Code (Primary):

Corporate Membership Profile

Number of employees engaged in customs brokerage work 50% of the time: *

Licence Holder

Individual Named on Licence: *

Job Title of Individual Named on Licence: *

Area(s) Where Licence Held:

Date Licence Issued: *

List Branch Locations:

Officers and Directors

CSCB Contact Name: *

Job Title: *

Email Address: *

Officer 1 Name: *

Officer 1 Job Title: *

Email Address: *

Officer 2 Name: *

Officer 2 Job Title: *

Email Address: *

References

(at least 2 of the 3 references must be employed with CSCB corporate member firms)

Reference 1 Name : *

Email Address: *

CSCB Corporate Member Firm: *

Reference 2 Name: *

Email Address: *

CSCB Corporate Member Firm: *

Reference 3 Name: *

Email Address: *

Firm Name: *

Reasons for Joining the CSCB: *

How did you hear about us?

Other: Please specify

Agreement to Abide by CSCB Code of Ethics

I, (individual named on customs broker licence): *

on behalf of (company name): *

acknowledge and agree to operate by the terms of the CSCB Corporate Member Code of Ethics.

Dated: *

Corporate Membership Application

Licence Holder

Officers and Directors

References

Agreement to Abide by CSCB Code of Ethics

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