Apply for Membership Order Number First Name and Last Name: * Designation: Mrs. Miss Ms Mr. Home Address: * Home Phone: Email Address: * Date of Birth: Certificate Language Preference: English French Business Name: * Business Address: * Business Phone: * Please send mail to: * Home Business I'm the * Owner Employee For how many years have you worked there? * I work * Full Time (<30hrs/wk) Part-Time Other... Modalities available at my business: * Galvanic Short wave Blend Electrolysis equipment/epilator owned: * Does your business meet Ontario Ministry of Health & Standards? * Yes No Not Sure Date of Last Public Health Inspection: * Method of Sterilization Used: * Autoclave Dry heat Chemical Other... Name and address of school where you received your electrolysis training: I received an electrolysis: * Diploma Certificate Year * Work experience in electrolysis: * Are you presently a member of any electrolysis organization? * Yes No Have you ever been a member of any electrolysis organization? * Yes No If yes, which one? If you left, why? How did you hear of the F.C.E.A.? * I hereby certify that all the information on this form is complete and correct to the best of my knowledge. If accepted, I promise to abide by the by-laws, rules and regulations of the Federation of Canadian Electrolysis Associations. Name as a digital signature: * Date of digital signature: