CIPPM Affiliation Application

Affiliates must abide by the Ethical Guidelines of CIPPM as set forth and amended from time to time; and must publish a statement of compliance with the Ethical Guidelines of CIPPM in all sales/development material and proposals. All sales/development material and proposals must also show the CIPPM logo without size reduction. The CIPPM logo will be provided in electronic format upon aceptance of your application.

Professional Information:

 Company:   

 Position:  

 Industry:  

 First Name:   

 Middle Name:  

 Last Name:    

 Honorific(s)/Degrees:  

 Street Address: 

 Post Address:   

 City:           

 State/Province: 

 Country:        

 Postal Code:    

 Response Preferred by:  
Electronic Mail
Telephone (Continental US only)
FAX



 Internet E-Mail Addresses
          (Primary):  

           (Backup):  

 Phone:  
 (include country & area codes)
 FAX:    
 Web or FTP Site where information can be viewed:  

I/We apply for Affiliate status. (Send proof of non-profit status & forms to CIPPM, 123 Charles, JXN, MI USA 49203.) You must send CIPPM a current copy of sales/development materials, company brochure/literature, etc... along with your payment.

I/We agree to provide the required documentation, and that final approval of this application will be considered upon recipt of required documentation. I/We agree to the terms and condtions set forth for becoming a Affiliate of CIPPM and its maintenance as declared by CIPPM; I/We understand that CIPPM may terminate relationship without notice iof I/we breach this undertaking or, at the discretion of CIPPM, it is felt that I/we have brought discredit upon CIPPM. (This box must be checked in order for your application to be considered.