Membership Application Form

Business Information:

Name:________________________________________________________________________

Business Name: ________________________________________________________________

Business Address:_______________________________________________________________

City:______________________________Province:___________ Postal Code ______________

Business Phone: (____)________________________ Fax: (____)_________________________

Email:________________________________Web Address:_____________________________
Electrolysis Training Information:

Name of Training School:_________________________________________________________

Address: ______________________________________________Province:________________

Postal Code:_____________Phone: (____)____________Email:__________________________

Date of Graduation:________________________Hours of Training: ______________________
Other Continuing Education and Certification:
(Enter date you passed these exams and forward a photocopy of certificate with application)

C.C.E - Canadian	Date:_______________
C.P.E. - Canadian	Date:_______________
R.E. - British Columbia	Date:_______________
C.C.E. - International	Date:_______________
C.P.E. - International	Date:_______________
R.D.T. - Canadian	Date:_______________

_________________________________________________	_______________________
Signature of applicant	Date

Sponsoring COPE Member's Name:______________________________Cope #_________
(List, above, the COPE National Member (if any) that was instrumental in your request to join COPE National).

Mailing Your Application For Membership

	Read and agree with your Membership Requirements
	Read and agree with the 'Code of Ethics'
	Read and agree with the Infection Control Standards
	Completed application form, sign and mail page one with the following
	Photocopies of all diplomas and certifications
	Your check for $100.00 (payment for 12 months starting with month of acceptance)

Mail application, check and copies of diplomašs and certifications to:

Melissa Newton
COPE Membership Chairman
29530 Sun Valley Cres.
Abbotsford, B.C. V4X 1J2
Phone: 1-504-857-4911 or Email: mknewton@dowco.com