IPA/Canada Membership Registration

Please fill in and then print and sign the following form. Send the
completed form along with your payment to IPA Canada. Thank You!


Send to: IPA Canada, 5304-190 Street, Edmonton, AB T6M 2L2
The following information will only be used by IPA to send you your Membership materials.

***Please fill in all fields.***

Name or Company:

Primary Contact (for companies):

Address:

City:

Province/Territory:

Postal Code:

Telephone:

Extension:

Email:


Membership types: (Chose one)

Total

Individual



Groups




$30.00
$70.00


$90.00
$110.00
$130.00


Signature:___________________________________________

Date:________________________________