CIP International Member Application

What type of international CIP membership are you applying for?:

Have you previously held CIP Membership?:

CIP Clauses:

I certify that CIP can send me email as required. Review the CIP privacy policy (see link above):

YesNo

I certify that the information I have provided on this form is correct, and that I am eligible for the membership category for which I am applying:

YesNo

I certify that I understand the CIP subscription and membership fees (or a prorated amount) are non-refundable:

YesNo

Organization/Employer (if applicable):

If you are currently a student, please enter the name of your educational institution:

If you are currently a student, please enter your degree Type (Please provide full title of degree - ex: Bachelor of Urban and Regional Planning):

If you are currently a student, please enter your expected year of graduation:

Please provide the following details:

Title:

First name:

Middle Name:

Last name:

Physical Address (where you are currently living):

City/Town:

Province/State:

Country:

Postal Code (ex. L1A 4M5):

Email:

This will be your login email address. Confirm email:

Birthdate:

Gender:

MaleFemaleNonbinary

Telephone:

Alternate Phone (Cell/Work):

Preferred Language:

Payment Preference - Credit card or cheque:

If you would like to pay by credit card, please provide the full name of cardholder:

Credit card number:

Expiry date:

CVC number (3 digit number beside the signature):

Display in Find a Member?:

YesNo

Opt out of Third Party Mail?:

YesNo

Address:	Adresse :	141 Laurier Avenue West, Suite 1112, Ottawa, ON K1P 5J3	141, avenue Laurier ouest, Bureau 1112, Ottawa (Ontario) K1P 5J3
Telephone number:	Tél :	800.207.2138 or 613.237.7526 (PLAN)	800.207.2138 ou 613.237.7526 (PLAN)