2
APPLICATION FORM RETAIL ASSOCIATE MEMBER Revised: 10/2017 Company Name: ________________________________________________________________________ Store Address: __________________________________________________________________________ City: _______________________________________________________ Postal Code: ______________ Mailing Address (if different from above): ___________________________________________________________________________ City: _______________________________________________________ Postal Code:_____________________________________ Work Phone: ________________________________________________ Fax: ____________________________________________ Toll Free: ___________________________________________________ Email: __________________________________________ Primary Contact: Name: ____________________________________________________________ Title: _______________________________________________ Phone: ___________________________ Cell: ____________________________ Email:_______________________________________________ Yes, I would like access to Homegrown Ontario™ branding. As a member in good standing of the Ontario Independent Meat Processors Association, I subscribe to the “Code of Conduct” as a condition of membership. Members shall; promote and foster fair trade practices in the best interests of consumers, members, suppliers, and the meat processing industry; shall maintain high standards to fully protect product safety, quality, and integrity; and shall comply with regulations and standards, as applicable to the goods and services they offer. Signature: _______________________________________________________________ Date: _______________________________ What prompted you to join? Collective Voice Member Discounts Consumer Outreach Networking Government Advocacy Technical Support Marketing Support Training Resources Referred by: ___________________________________ Other (specify): ___________________________________ Payment Information Retail Associate Dues $175.00 Cheque # ___________ Enclosed (payable to the Ontario Independent Meat Processors) HST (# 121262919) $22.75 Charge to my: VISA MasterCard Expiry Date: Total Amount Due $197.75 Card #: Membership is valid for one year from the date dues are received. Cardholder Name: Signature: We now accept Electronic funds transfers and E-Transfers - Call to receive deposit information. OIMP office use only: Date: ___________ Company ID #___________ Cheque/Authorization #___________ QuickBooks Processing Sheet Membership is subject to approval by the OIMP Board of Directors. Membership in the Association may be terminated at the request, in writing, of the member; when a member fails to be current with membership dues; member declares bankruptcy or dissolution of the partnership, corporation or business entity; if conduct of the member is deemed by the Board to be detrimental to the interests of the Association. An aggrieved member shall have the right of appeal to the Board of Directors. Membership fees will not be refunded in whole or in part. OIMP values the privacy of its members. All information collected is done so in accordance with our Privacy Policy. Email addresses provided on this form act as your consent to receive electronic communications from OIMP. You may request to be removed from our lists at anytime. Additional Company Contacts: Secondary _______________________________________________ Email: ___________________________________________________ Regulatory _______________________________________________ Email: ___________________________________________________ Accounts Payable _______________________________________________ Email: ___________________________________________________ Sales/Marketing _______________________________________________ Email: ___________________________________________________ Human Resources _______________________________________________ Email: ___________________________________________________
