Membership Registration Form

WE ARE ALL IN THIS TOGETHER

First Name (Legal Name)*

Last Name (Legal Name)*

Email Address*

Telephone*

Mailing Address*

Are you Regulated Canadian Immigration Consultant (RCIC)?*

Membership Type (please choose one):*

Name of Institution (required for student)

Student ID/Number (required for student)

Date Graduated/Expecting To (required for student)

Languages Spoken

Years of Practice

Area of Practice

Business Name (For corporate member)

Business address (For corporate member)

Business Phone number and Email (For corporate member)

Company Director’s Name, Phone Number and Email (For corporate member)

Employees of the above company who would like to be enrolled under the Corporate Category. Please Provide Employees’ Legal Name, Phone Number, Email and if RCIC or Student? (For corporate member)

Terms and Conditions： I have carefully read and understand the Terms and Conditions of this application and agree to be bound by the related terms and conditions.*

Terms and Conditions：By submitting this form, I hereby declare that the information provided is true and correct. I also understand that any willful dishonesty may render for refusal of this application or immediate termination of my membership status.*

If you heard abour RCIC CLUB from referral, please provide the name of referral

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