Facility Dues

Facility Name*

Address*

Street Address Address Line 2 City Postal Code

Facility Phone*

Facility Email*

Facility Owner/Manager 1 Name*

Surname Given Name(s)

Facility Owner/Manager 1 Phone*

Facility Owner/Manager 1 Email*

Facility Owner/Manager 2 Name (if applicable)

Surname Given Name(s)

Facility Owner/Manager 2 Phone (if applicable)

Facility Owner/Manager 2 Email (if applicable)

Facility Owner/Manager 3 Name (if applicable)

Surname Given Name(s)

Facility Owner/Manager 3 Phone (if applicable)

Facility Owner/Manager 3 Email (if applicable)

Number of Certifees*

Certifee 1 Name*

First Last

Certifee 1 Certification*

CP(c)
CO(c)
CPO(c)

Certifee 2 Name*

First Last

Certifee 2 Certification*

CP(c)
CO(c)
CPO(c)

Certifee 3 Name*

First Last

Certifee 3 Certification*

CP(c)
CO(c)
CPO(c)

Certifee 4 Name*

First Last

Certifee 4 Certification*

CP(c)
CO(c)
CPO(c)

Certifee 5 Name*

First Last

Certifee 5 Certification*

CP(c)
CO(c)
CPO(c)

Certifee 6 Name*

First Last

Certifee 6 Certification*

CP(c)
CO(c)
CPO(c)

Certifee 7 Name*

First Last

Certifee 7 Certification*

CP(c)
CO(c)
CPO(c)

Certifee 8 Name*

First Last

Certifee 8 Certification*

CP(c)
CO(c)
CPO(c)

Date*

By signing the Membership Application/Renewal form, you are agreeing to abide by the terms and conditions of the Memorandum of Understand (MOU – 2). Note: Facility dues are for a 1-year term from July 1, 2023 - June 30, 2024.

Facility

Dues

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