Regular Membership Application Form

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1. Organization/Company Name

Organization/Company Name

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2. Primary Contact Name

Primary Contact Name

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3. Title

Title

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4. EMail

EMail

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5. Phone

Phone

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6. Mailing Address

Mailing Address

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7. FAX

FAX

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8. Business Type?

	Type
Business	Local GovernmentRegional DistrictFirst NationTelcommunicationOil & GasHydro Transmission or DistributionRail serviceOther Business Type?   Business   Type

Other (please specify)

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9. Describe your business (if First Nations please identify the bands represented)

Describe your business (if First Nations please identify the bands represented)

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

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

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11. What areas of the province are of interest to your company

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

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

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

	Monthly	Quarterly
Currency	*How often will the data be updated and delivered to ICIS? Currency Monthly	Currency Quarterly

Other (please specify)

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

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

15. Additional Comments

Additional Comments

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16. Name of Signing Authority

Name of Signing Authority

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17. Title

Title

18. Address - if different than above

Address - if different than above

19. EMail - if different from above

EMail - if different from above

20. Phone - if different from above

Phone - if different from above

21. Fax - if different from above

Fax - if different from above