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Title:  Dr. Mr. Mrs. Miss Ms. Surname:  Given Name:  Firm Name:  Address:  City:  Province:  Country:  Postal Code:  Telephone:  Direct line: YesNo Fax:  E-mail:  Class of membership applied for: Associate Affiliate Academic Student Definitions QUALIFICATIONS: Please choose all that apply: Lawyer Patent Agent Patent Agent/Trade-Mark Agent Trainee Trade-Mark Agent Indicate from among paragraphs (d) to (j) of By-Law 1 (click here), the particular paragraph and sub-paragraph(s) on which this application is based. Give facts on which applicant relies, to establish that the requirements of the said paragraph and sub-paragraph(s) are satisfied. Please include a cheque or money order (in Canadian funds) for the following amount: $332.00 (CDN) ASSOCIATE or AFFILIATE $155.00 (CDN) ACADEMIC $50.00 (CDN) STUDENT Add 5% GST (AB, SK, MB, QC, PEI, YT, NT, NU) OR 12% HST for BC OR 13% HST for ON, NB, NL OR 15% HST for NS This is the annual fee for the year in which the applicant becomes a member; there is no additional entrance fee. NOTE: You must include your e-mail address to submit this form. This form, together with your cheque should also be sent to us by mail at the address given on the home page. All applications are acknowledged upon receipt. IPIC GST REGISTRATION NO. R122871148 Date: mm/dd/yyyy © 2010 Intellectual Property Institute of Canada, Ottawa, ON 613.234.0516