Contact

Affiliate Application

Organization Information

Organization Name

Type of Organization

Other

Organization Size (Employees)

Are you a publicly traded company? YesNo

Description of operations:

Which province/territory is your base of operations?

How are you currently engaging with License Holders? (If not in active engagement with LHs, type in N/A)

Other Notes

Contact Information

Address of Operations

City/Town

Postal Code

Website

Primary Contact: The Primary Contact is usually the President, CEO, or Executive Director of your organization

Primary Contact Name

Primary Contact Title

Primary Contact Phone Number

Primary Contact Email

Secondary Contact

Secondary Contact Name

Secondary Contact Title

Secondary Contact Phone Number

Secondary Contact Email

Enter Today's Date (DD/MM/YY)

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