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Periodical Membership Form

Please complete the following form and send a copy to us by hitting submit at the bottom

Your Name
Name of Publication
Address
City
Province	Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Postal Code
Telephone
Fax
E-mail
Website
Publisher (Organization)
Mission / Purpose Statement
Staff that you wish to be listed in the directory (editorial, art, advertising, administrative):
1 Name / Title
2 Name / Title
3 Name / Title
4 Name / Title
5 Name / Title
Circulation (paid)
Circulation (unpaid)
Frequency
Format
Subsciption Price
Paid advertising accepted?	Yes No
Freelance material accepted?	Yes No
Affirming the constitution, code of ethics and the information provided above,
E-mail signature and title
Date

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