Apply for Membership Name First Name and Last Name: * Date of Birth: Home Address: * Cell Phone: * Home Phone: Email Address: * BUSINESS INFORMATION Please provide as much detail as possible if you're just starting out. We can always update it later. Business Name: Business Website: Business Address: Business Phone: Business Social Media Profiles: Are you the the owner or employee of the business? Owner Employee For how long have you worked as an electrologist? I work Full Time (<30hrs/wk) Part-Time Other... Modalities available at my business: Galvanic Short wave Blend Electrolysis equipment/epilator owned: Has your business been Health Inspected by a regional health unit (according to, Ontario Ministry of Health)? Yes No Not Sure Date of Last Public Health Inspection: Method of Sterilization Used: Autoclave Dry heat Chemical Other... TRAINING INSTITUTE INFORMATION Please let us know about your training. Training Institute Name I received an electrolysis: * Diploma Certificate Year * Modalities learned: * Galvanic Short wave Blend Date training completed: * Are you presently a member of any electrolysis organization? * Yes No If yes, which one? 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: