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Membership Application
First Name*
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Last Name*
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Company Name(if applicable)
Address*
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City*
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Province*
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
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Postal Code*
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*This is not a valid postal code. (ie A2A 2A2)
Home Phone*
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*This is not a valid phone. (ie 555-555-5555)
Cell Phone
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E-mail*
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*This is not a valid email.
I agree with your terms and conditions*
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Gross Sales*
$0 - $99,999
$100,000 - $249,999
$250,000 - $499,999
$500,000 - $749,999
$750,000 - $999,999
$1,000,000 - $1,249,999
$1,250,000 - $1,499,999
$1,500,000 - $1,749,999
$1,750,000 - $1,999,999
$2,000,000 - $2,249,999
$2,250,000 - $2,499,999
$2,500,000 - 2,749,999
$2,750,000 - $2,999,999
$3,000,000 - $3,249,999
$3,250,000 - $3,499,999
$3,500,000 - $3,749,999
$3,750,000 - $3,999,999
$4,000,000 - $4,249,999
$4,250,000 - $4,499,999
$4,500,000 - $4,749,999
$4,750,000 - $4,999,999
$5,000,000 - $5,249,999
$5,250,000 - $5,499,999
$5,500,000 - $5,749,999
$5,750,000 - $5,999,999
$6,000,000 - $6,249,999
$6,250,000 - $6,499,999
$6,500,000 - $6,749,999
$6,750,000 - $6,999,999
$7,000,000 - $7,249,999
$7,250,000 - $7,499,999
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Payment Method (please check one)*
invoice
paypal payment
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Would you like to be added to PEI Aquaculture Alliance mailing and email distribution lists to receive industry news and updates? (please check one)*
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Yes
No
What is your most preferred method of communication?
Email
Mail
Phone
What aspects of the industry are you involved in.(Select All That Apply)
Finfish
Mussels
Oysters
Processor
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I authorize the verification of the information provided on this form. I acknowledge that my electronic signature on this document is legally equivalent to my handwritten signature. *
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Date*
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