Application Form Company Information Company Name * Date (MM/DD/YYYY) * Company Address * City * Postal Code * Province * ABBCMBNBNLNSNTNUONPEQCSKYT Phone Number * Company Contact Contact Name * Email * Position * Telephone * Location Information Total Number of Site Locations * None34567 Site 1 Address * City * Province * ABBCMBNBNLNSNTNUONPEQCSKYT Number of Employees * WCB Industry Code(s) * WCB Account # * Company Contact * Position * Telephone * Cell Fax * E-mail * Site 2 Address City Province - None -ABBCMBNBNLNSNTNUONPEQCSKYT Number of Employees WCB Industry Code(s) WCB Account # Company Contact Position Telephone Cell Fax E-mail Please Note: Minimum fee is $100.00 + GST, Maximum fee is $10,000 + GST Previous Year WCB Assessable Payroll * Yearly Rate Base Membership Fee GST (5%) Total Fees Due Membership fees are based on a January to December term. Any membership after February will be pro-rated. Pro-rate membership Month Membership Begins - None -JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Total Fees Due I am authorized to provide MHSA access to the employers' WCB estimated payroll for membership invoicing purposes. * I am authorized to provide MHSA access to the employers' WCB estimated payroll for membership invoicing purposes. By submitting this application you are agreeing to receive electronic messages from the Manufacturers’ Health & Safety Association MHSA. At any time you may unsubscribe if you no longer wish to receive our emails.