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, PO box 52022, Edmonton Alberta T6G 2T5
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

$29.00
$65.00


$80.00
$100.00
$120.00


Signature:___________________________________________

Date:________________________________