APPLY FOR MEMBERSHIP

Name of Company*
"hereby applies to become a member of FCSA"
Address*
Street Address Address Line 2 City Province Postal Code
Type of Telecommunications Service Provider*
- Local Telephone
- Long Distance Telephone
- Cellular
- PCS
- Hydro Utility
- CATV
- Internet
- Other (Specify)
Number of Operating Microwave Radio Stations*
Total Amount of Microwave License Fees paid to Industry Canada on April 1 of Current Year: $*
Reason for Seeking Membership in FCSA*
On behalf of Applicant - Name*
First Last
On behalf of Applicant - Title
SPONSORSHIP #1
(Two required)
Name*
First Last
Organization*
SPONSORSHIP #2
Name*
First Last
Organization*

SPONSORSHIP #1