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Title:  Dr. Mr. Mrs. Miss Ms. Surname:  Given Name:  Firm Name:  Address:  City:  Province:  Country:  Postal Code:  Telephone:  Direct line: YesNo Fax:  E-mail:  Class of membership applied for: Associate Affiliate Academic Student Definitions QUALIFICATIONS: Please choose all that apply: Lawyer Patent Agent Patent Agent/Trade-Mark Agent Trainee Trade-Mark Agent Indicate from among paragraphs (d) to (j) of By-Law 1 (click here), the particular paragraph and sub-paragraph(s) on which this application is based. Give facts on which applicant relies, to establish that the requirements of the said paragraph and sub-paragraph(s) are satisfied. In order for your application to be processed, please include a cheque or money order (in Canadian funds) for the following amount: $346.00 (CDN) ASSOCIATE or AFFILIATE $161.00 (CDN) ACADEMIC $50.00 (CDN) STUDENT Add 5% GST (AB, SK, MB, QC, PEI, YT, NT, NU) OR 12% HST for BC OR 13% HST for ON, NB, NL OR 15% HST for NS This is the annual fee for the year in which the applicant becomes a member; there is no additional entrance fee. NOTE: You must include your e-mail address to submit this form. This form, together with your cheque should also be sent to the IPIC office located at: 606-60 Queen Street Ottawa, ON K1P 5Y7 All applications are acknowledged upon receipt of form and payment. IPIC GST REGISTRATION NO. R122871148 Date: mm/dd/yyyy © 2010 Intellectual Property Institute of Canada, Ottawa, ON 613.234.0516