Your First Name

Your Last Name

Company Name

E-Mail Address (for listing and quote requests)

Web Site URL

Do you offer the following:

Bilingual Services

Hearing Impaired Services

Other Specialty :

Brief Description of Services

Areas Serviced (list boundries, intersections etc. separate by comma)

Listing Categories - ACPSN Reserves the right to limit listings to those areas which are the most relevant. Companies requesting to be listed in areas in which they are not physically located, or requesting listings in numerous areas will be subject to approval before posting. Listings will not be posted in areas that are not within your normal service area.

- Select Location - Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario PEI Quebec Saskatchewan Yukon ------

- Select Location - Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario PEI Quebec Saskatchewan Yukon ------

- Select Location - Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario PEI Quebec Saskatchewan Yukon ------

If "Other" Type name of category for web index:

Would you like a:

Basic Listing
Enhanced Listing (Additional $15)

For enhanced listings only, please provide additional information to be included on the enhanced page:

Membership Applications will not be processed without a valid street address. We will not rely in addresses provided by Paypal or other means. Please complete your address here.

Street Address 1

Street Address 2

City

Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Ontario PEI Quebec Saskatchewan Province

Postal Code

Primary Telephone Number (to appear in Listing)

Seconday Telephone Number (For Contact by ACPSN only)

How many membership cards do you require? (First 2 cards are free, up to 5 additional cards @ $2.00 each)

Only one card is issued per name. If no names are specified, only the contact person submitting this form will receive a membership card. Please specify the names as they are to appear on the cards. Separate names by a comma.

Company logos and additional files may be uploaded here. For enhanced listings: If you are experienced in web design and would like to design your own page, please e-mail the .html file as an attachment, as well as any other graphic files appearing on the page. If you create your own page design, you are permitted to use any of the following file types in your page: JPG, GIF, BMP.