CSCB Membership Application Organization Information Organization Name Address 1 Address 2 City Province - Select -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Territory Postal Code Email Address Phone Fax Website Applicant Information First Name Last Name Job Title Email Address Member Firm Profile Number of employees at your company Number of employees engaged in customs brokerage work 50% of the time Name of Qualified Officer Date Licence Issued Year Year191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Branch Locations Officers and Directors CSCB Contact Name Job Title Email Address Officer 1 Name Officer 1 Job Title Email Address Officer 2 Name Officer 2 Job Title Email Address Reasons for Joining the CSCB How did you hear about us? Advertisement Employee(s) Social media networks (eg. LinkedIn, Facebook, Twitter) Current member Client/supplier Web search Email Agreement to Abide by CSCB Code of Ethics I, (individual named on customs broker licence) on behalf of (company name) acknowledge and agree to operate by the terms of the CSCB Member Code of Ethics. Dated Year Year202320242025 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031