Affiliate Membership Application Form

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* 1. Organization/Company Name

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* 2. Primary Contact Name

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* 3. Title

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* 4. EMail

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* 5. Phone

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* 6. Mailing Address

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* 7. FAX

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* 8. Business Type?

	Type
Business	Business Type menu

Other (please specify)

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* 9. Describe your business

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* 10. Does your organization wish to access ICIS data (If the answer is "NO" go to question #17)

YES

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* 11. How will the ICIS Member data be used? (Note: Please read the "General Terms and Conditions" and "ICIS Membership Policy")

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* 12. What areas of the province are of interest to your company

ALBERNI CLAYOQUOT RD RURAL

BULKLEY NECHAKO RD RURAL

CAPITAL RD RURAL

CARIBOO RD RURAL

CENTRAL COAST RD RURAL

CENTRAL KOOTENAY RD RURAL

CENTRAL OKANAGAN RD RURAL

COLUMBIA SHUSWAP RD RURAL

COWICHAN VALLEY RD RURAL

EAST KOOTENAY RD RURAL

FRASER FORT GEORGE RD RURAL

GREATER VANCOUVER RD RURAL

ISLANDS TRUST

KITIMAT STIKINE RD RURAL

KOOTENAY BOUNDARY RD RURAL

MOUNT WADDINGTON RD RURAL

NANAIMO RD RURAL

NORTH OKANAGAN RD RURAL

OKANAGAN SIMILKAMEEN RD RURAL

PEACE RIVER RD RURAL

POWELL RIVER RD RURAL

SKEENA QUEEN CHARLOTTE RD RURAL

SQUAMISH LILLOOET RD RURAL

SUNSHINE COAST RD RURAL

THOMPSON NICOLA RD RURAL

Comments

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* 13. What data does your organization/company own and is willing to share with ICIS Members?

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* 14. How often will the data be updated and delivered to ICIS?

	Monthly	Quarterly
Currency	Currency Monthly	Currency Quarterly

Other (please specify)

Question Title

* 1. Organization/Company Name

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* 2. Primary Contact Name

Question Title

* 3. Title

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* 4. EMail

Question Title

* 5. Phone

Question Title

* 6. Mailing Address

Question Title

* 7. FAX

Question Title

* 8. Business Type?

Question Title

* 9. Describe your business

Question Title

* 10. Does your organization wish to access ICIS data (If the answer is "NO" go to question #17)

Question Title

* 11. How will the ICIS Member data be used? (Note: Please read the "General Terms and Conditions" and "ICIS Membership Policy")

Question Title

* 12. What areas of the province are of interest to your company

Question Title

* 13. What data does your organization/company own and is willing to share with ICIS Members?

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* 14. How often will the data be updated and delivered to ICIS?

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* 15. Will there be any restrictions on the data other than those imposed by the DSLA?

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* 16. Additional Comments

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* 17. Name of Signing Authority

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* 18. Title

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* 19. Address - if different than above

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* 20. EMail - if different from above

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* 21. Phone - if different from above

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* 22. Fax - if different from above