Membership Application Form – old Company Company Information Company Name * Company Address * Country * Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia, Plurinational State of Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, the former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Province/State * City * Postal/Zip * Contact Information Contact Name * Contact Title * Contact Email * Contact Phone Contact Cell Webpage Where and when was your company incorporated or established? * What is the legal nature of your “company”? * Please provide two references, including company name (if applicable), contact person, address, telephone, and email address. One reference is sufficient if the reference is a Member of the Association and has a business relationship with your company. For applicants that provide consulting services, references must be from a company with an offset (IRB/ITB/VP) obligation in Canada. Please provide complete contact information for your reference(s). Reference 1 Company Name Name * Title * Email * Phone * Reference 2 Company Name Name Title Email Phone Why do you wish to join the Association and how did you hear about the Association? If it was through a Member, please list who it was. * Applicant * Agreement List * - I hereby certify that my company had, has or expects to have an IRB/ITB/VP obligation, or is supporting as a consultant a company or companies which have or expect to have an IRB/ITB/VP obligation. Agree2 - I hereby certify that if approved to become a Member, I will be bound by and obey the Bylaws of the Industrial Participation Association of Canada (IPAC), including an obligation to pay annual dues to maintain membership in good standing, and comply with the policies applicable to Members, including but not limited to, its Antitrust Policy and Non-Discrimination Policy. Copies of the Bylaws and above referenced policies will be made available upon request. An invoice for annual dues will be sent once membership has been approved by the Executive Committee. Agree3 - I hereby certify that the applicant (prime contractor, subcontractor, business entity, or individual) is not included on any denied party and similar lists in its country of formation, and the applicant (and its owners and affiliates) is not listed on any denied party and similar lists maintained by Canada and/or the jurisdiction of the applicant. Agree4 - I hereby certify that the company is duly organized and in good standing in its jurisdiction of formation. Agree5 - I understand that only employees or partners are entitled to the benefits of membership in the Association, including representation at meetings, conferences, training, etc. Subcontractors, non-affiliated companies and consultants to Members are not permitted to benefits of a membership unless they are Members as well. Annual IPAC Membership fees cover the period January through December and are invoiced in January of each year, payable upon receipt.