Group membership form-Caregiver Marketplace

MEMBERSHIP APPLICATION GROUP

Instructions:

Please fill in all *required information.

Make your selection for payment. Fees will be processed within two days. Caregiver Marketplace is a secure site and we guarantee your information is protected.

Receipt of payment will be available for your records.

Fax or scan your signed application and send to:

Fax: 403-253-9360 Caregiver Marketplace with original signature to activate your membership .

Email: membership@caregivermarketplace.com to activate your membership

Member Information:

Organization name:

Other business names:

Legal name:

Address:

Mailing Address if different:

City/Province:

Postal Code:

Contact Name:

Type of Care: Please check appropriate care program and care group	program:	elder care	childcare	family childcare	preschool program
		specialized care	pet care	other

	group:	infant carecare	preschool care	schoolage care
		elder care	pet care	other

Contact Information:

Head Office:

Phone No.:

Cell No.:

Email address:

Website address: do you have one? yes no if yes, what is your URL?

Name of organization chair or president: Has signing authority? yes no

* Payment Options:

*Choose one of the following payment options:

Note: Caregiver Marketplace offers a secure site to protect your information. Fees are effective January 1, 2005

All fees are exclusive of GST and PST please add appropriate tax.

No of employees	Fees	Discount	√ Check applicable column
1 - 5	$ 135.00	10%
6 - 10	$ 264.00	12%
11 – 20	$ 480.00	20%
21 - 30	$ 685.00	25%
31 – 40	$ 840.00	30%
41 - 50	$1020.00	32%

Visa MasterCard American Express

Number of Card:

Expiration Date: (mm yy)

Name on Card:

Total fees to be processed: Fees $ ________________ Plus PST/GST: $_________________ = total fees payable $________________

I, ____________________________________, do authorize activation of my membership and will allow Caregiver Marketplace to process fees on my credit card.

Authorized Signature:_______________________________________________________________

Print Name: ______________________________________________________________________

Date: ___________________________________________________________________________

* Declaration and authorization:

I, _____________________________________________ declare the information on this application to be truthful. I do understand this application for membership is submitted for review and does not become effective until application has been approved by Caregiver Marketplace and fees are received and paid in full. I understand that this membership will become effective on the first day of the month following receipt of application and fees.

Name: __________________________________________

Signature: __________________________________________

Once membership fees have been processed, there are no prorates or refunds.