CREDIT INSTITUTE OF CANADA

219 Dufferin Street, Unit 216C, Toronto Ontario, M6K 3J1 tel. 416-572-2615 fax. (416) 572-2619

WEBSITE: http://www.creditedu.org

APPLICATION FOR AFFILIATE MEMBERSHIP

PERSONAL

SURNAME	INITIAL	GIVEN NAME	OTHER DESIGNATIONS
STREET ADDRESS			YEARS IN CREDIT
CITY	PROVINCE	POSTAL CODE
HOME PHONE	BUS PHONE	FAX NUMBER	E MAIL ADDRESS

EMPLOYMENT

COMPANY NAME			TYPE OF BUSINESS
COMPANY ADDRESS			POSITION HELD
CITY	PROVINCE	POSTAL CODE

REASON FOR JOINING

AGREEMENT

I hereby declare that contingent upon my being admitted as an Affiliate member of the Credit Institute of Canada, I agree to be bound by the provisions of the Institute and its Chapters, to abide by the General By-Laws and Standing Rules, and to comply with the Institute’s Code of Ethics.

I hereby agree to make every effort to complete at least one of the following: CCP courses, one Credit Institute National Conference, a Credit Basics course, attend a Forum meeting, two Credit Institute seminars or attend eight dinner meetings within each and every three year period.

I enclose the amount of $_________ (which consists of National Dues plus G.S.T. and applicable Chapter Dues*) representing my application for and undertake, so long as I am an Affiliate member, to pay on receipt of such annual dues as has been determined by the Board of Directors.

*Fees for Chapter membership varies from Chapter to Chapter. Please contact the National Office of the Credit Institute of Canada for specific details.

The Credit Institute of Canada membership information obtained through any membership with the Credit Institute is private and confidential. Any unauthorized solicitation to Credit Institute of Canada members is strictly prohibited as is the publishing or sale of Credit Institute of Canada membership information. Any violators may be subject to punitive damage/legal action.

SIGNATURE OF APPLICANT

DATE