Manufacturer - Application for Membership

Company Name *

Address Line 1 *

City *

Province *

Postal Code *

Phone *

Fax

Email *

Website

President of Company *

Applicant Name *

Position *

Signature *

Please check where appropriate *

Does the company have a substantial investment in a factory and/or machinery in Canada used to manufacture plumbing, heating, hydronics, waterworks and industrial products?

Enter required value Yes No

List the products you manufacture that fall into these categories *

List the general types of plumbing, heating, hydronics, waterworks and industrial products you manufacture in Canada:

Date company established? *

Year:

How long has it been under the present ownership *

Years:

Is it registered or incorporated in Canada *

Yes

Federally

Provincially

No

Is the company affiliated with any other Canadian company *

Enter required value Yes No

Is the other company in the plumbing and heating industry *

Enter required value Yes No

Please give the name of the other company from the previous question and explain the relationship *

Put N/A if 'no' was selected in the previous question

What percentage of the company’s sales are to *

Wholesaler distributors *	Contractors *	Builders *	Consumers *	Retailers *	Industrial *	Others (specify) *
							Del

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How many employees does the company have in Canada *

Enter required value Under 5 5-9 Over 10

Please select all that apply *

Into which provinces are the company’s plumbing, heating, hydronics, waterworks and industrial products distributed?

All 10

BC

AB

SK

MB

QC

NB

NS

PE

NL

If Applicable, Please list the Manufacturer's Agent companies who represent your products in Canada

Canada's Anti-Spam Legislation fulfillment: Yes, I agree to receive e-communications from CIPH

List key employees of the company

Name	Title	Location	Email
				Del

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To assist the CIPH Membership committee with their recommendation *

Please indicate top three reasons why you want to become a member of the institute

Please list subsidiaries, if any *

Basic Dues (Canadian Annual Including subsidiaries) *

Please select appropriate option.

On Sales of over $50 million *	On Sales of $25 to $50 million *	On Sales of $10 to $25 million *	On Sales of over $1 to $10 million *	Basic Dues *
$6,075	$5,180	$3,670	$2,130		Del

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Additional Dues *

$150 Dues for each of the ten provinces in which your plumbing, heating, hydronics, waterworks and industrial products are distributed and sold either directly or indirectly.

Annual dues / Subtotal (Basic dues plus additional dues) *

PLUS GST/HST per Province of origin (calculated in last item) *

Registration #10686 1669RT0001

AB - 5%

BC - 5%

MB - 5%

NB - 5%

NL - 15%

NT - 5%

NS - 15%

ON - 13%

PE - 15%

QC - 5%

SK - 5%

NU - 5%

YU - 5%

TOTAL DUES (Annual dues / Subtotal + GST) *

Signing Officer *

Title *

Signature *

Please provide your Full name