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Pest Management Advisory Council - Membership Application Form
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(PDF Version - 106 K)Pest Management Advisory Council Membership Application Form
Candidate Information
Last Name:
First Name:
Gender: M ( ) F ( )
Language:
Citizenship:
Company/Organization:
Title:
Street Address:
City:
Province:
Postal Code:
Telephone (specify work, home, mobile, other):
Fax:
Email Address:
Current Professional Position:
Since (Year):
Area(s) of Responsibility:
Concurrent or Past Professional Affiliations:
Organization Information
Name:
Contact Information:
Purpose/Mandate:
Areas of Activity:
All information and documents received will be kept confidential under the federal 
Privacy Act and Access to Information Act. Unless applicants request otherwise, the Pest Management Advisory Council Secretariat will retain the submitted information and documents for three years for future consideration.
For more information on how Health Canada manages personal information, contact the Pest Management Information Service.
