Company legal name:
Company operating name:
Authorized representative (holds company vote in ACSESS):
Name:
Title:
Most senior Canadian official, if different from above:
Name:
Title:
Address:
Suite:		City:
Province:		Postal Code:
Telephone:		Fax:
E-Mail:
Website:
Federal BN:
Language Preference:	English     French
BUSINESS INFORMATION
1. Permanent placement/search services must provide their provincial license where applicable:
Class:
Number:
2. Temporary help companies and contract providers must supply WSIB/WCB (CSST) clearance certificate. 3. For companies/locations with more than 5 full-tme employees, please provide the name of the Health and Safety representative (if provincially required).
Name:
Phone:
COMPANY PROFILE
Year business commenced:
Number of offices in Canada:
Are you a member of any other industry organization?	Yes     No If yes, please list:
How did you hear about ACSESS?
What is your primary reason for joining ACSESS?
SERVICE PROFILE
Indicate the type(s) of staffing services your firm provides by noting the percentage of your sales they represent. 1. Direct-hire / Executive search services Yes     No % 2. Temporary services Yes     No % 3. Contract staffing Yes     No % 4. Other services (e.g., PEO, payroll, managed services, etc.) Yes     No %   Total should = 100%
DUES PAYMENT
Membership year is January 1 to December 31. Dues are subject to 5% GST (#871631198) and must be submitted with the application. 1st office: $795 2nd office: $645 Each addtional office: $550 Affiliate: $795 Candidate Member: $150 CPC Member: $250 How would you like to pay? Cheque (please make cheque payable to ACSESS) VISA     MasterCard     AMEX
Authorization The undersigned hereby applies for membership in the Association of Canadian Search, Employment & Staffing Services (ACSESS). I, on behalf of my company, hereby pledge to adhere to the Code of Ethics & Standards of ACSESS in the best interests of the industry and the public that it serves.
Authorized signature:
Date: