Platinum Level Membership Application Form - New or Renewal

Type of Membership

Platinum Level - 1500.00 + GST

Fields marked with * are required.

Membership number (if known)

First name

A value is required. *

Last name

A value is required. *

Organization

A value is required. *

Position/Title

Mailing Address

* A value is required.

City

* A value is required.

Province

* A value is required.

Postal Code

* Invalid format. Must be Uppercase, like:"X1X X2X", including the blank space.A value is required.

Telephone

* A value is required.Invalid format.

Fax

* A value is required.Invalid format.

Training Coordinator

Training Email

Chair

Chair Email

Voting Representative Name

Please forward all correspondence attention to:

Please add my contact information as a FAJ member to a hard copy list

Please add my contact information as a FAJ member to the FAJ members only website

PayPal

Invoice me (Platinum or Silver Membership only)

I will send cheque to:

Please select payment method above.

Foundation of Administrative Justice
3438 - 78 Ave
Edmonton, AB T6B 2X9
Phone:780-466-0501
Fax: 780-466-8015

GST Exemption #

Subtotal