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Member Application Form (Canada)
1. IDENTIFICATION
LAST NAME
FIRST, SECOND AND THIRD NAMES

ADDRESS

CITY
PROV/STATE
COUNTRY
POSTAL / ZIP CODE
Provide any legal names, other than the name given in 1, and assumed names by which you have carried on business or otherwise been known, such as a registered sole proprietorship. Please include any name change(s) resulting from marriage, divorce, court order or other process. FROM TO
Y M Y M
2. EDUCATIONAL HISTORY- Provide your educational history starting with the most recent.
INSTITUTION LOCATION DEGREE OR DIPLOMA DATE OBTAINED
Y M D

PROFESSIONAL DESIGNATION - provide any professional designation held, for example Barrister & Solicitor, C.A, C.G.A., P.Eng, P. Geo and C.F.A. and indicate by whom and the date the designations were granted.

PROFESSIONAL DESIGNATION GRANTER OF DESIGNATION DATE GRANTED IN EFFECT - YES or NO
Y M D

Yes No

Yes No

3. EMPLOYMENT HISTORY- provide your employment history for the 10 years immediately prior to the date of this form starting with your current employment.

EMPLOYER NAME EMPLOYER ADDRESS FROM TO
Y M Y M

4. PERSONAL INFORMATION

A.
RESIDENTIAL TELEPHONE NUMBER BUSINESS   TELEPHONE NUMBER FAX NUMBER EMAIL (INTERNET)
B.
MARITAL STATUS FULL NAME OF SPOUSE - include common law OCCUPATION OF SPOUSE
C.
DATE OF BIRTH PLACE OF BIRTH
Y M D CITY PROVINCE / STATE / PARISH COUNTRY
D.
CITIZENSHIP
If you are not a Canadian citizen:
[1] Are you a permanent resident of Canada?
YES NO
[2] What is your Nationality?  
 
If yes, number of years of continues residence in Canada: years
PASSPORT COUNTRY OF ISSUE NAME OF CITY WHERE PASSPORT WAS ISSUED DATE PASSPORT ISSUED PASSPORT NUMBER
Y M D
E.
DRIVER'S LICENSE NUMBER PROVINCE / STATE WHERE DRIVER'S LICENSE WAS ISSUED SOCIAL INSURANCE / SECURITY NUMBER

5. RESIDENTIAL HISTORY- Provide all residential addresses for the past 10 YEARS starting with your current principal residential address.

STREET ADDRESS, CITY, PROVINCE/STATE, COUNTRY & POSTAL / ZIP CODE FROM TO
Y M Y M

6. POSITIONS IN OTHER ISSUERS - If you were employed or engaged by an Issuing entity, please provide the names of reporting issuers and of issuers with continues disclosure obligations in other jurisdictions of which you are now, or during the last five years, have been a director, officer, promoter or control person, the positions you held and the periods during which you held those positions.

NAMES OF (REPORTING) ISSUERS POSITION HELD WITH ISSUER FROM TO
Y M Y M
7. PERSONAL REFERENCES - Provide two (2) references for HD Faculty to consult as and when required.
NAME OF REFERENCE :
COMPANY/INSTITUTION NAME:
RELATION TO REFERENCE:
COUNTRY:
CONTACT PARTICULARS: tel. no.:
   
e-mail address:

NAME OF REFERENCE :
COMPANY/INSTITUTION NAME:
RELATION TO REFERENCE:
COUNTRY:
CONTACT PARTICULARS: tel. no.:
   
e-mail address:

8. MANAGEMENT FACULTY RELATED INQUIRIES - Though the particulars as provided in point 1 to 7 above are for internal purposes only, this section allows you to provide management faculty related particulars and preferences that will be posted on the relevant area of our web-site, accessible by authorized users only (if approved!).
By filling out this section, and consequently submitting this application form, you give consent to HD Faculty to upload the information provided in this section 8 on the HD Faculty web-site area as mentioned above.

Select the faculty you are applying for :
Qualifications Title :
Years :
Languages Fluent :
Basic :
Place of Employment Based in :
Transitory : (are you willing and in a position to be relocated)
Availability F/P : Full Time Part Time
CBC : (click, if available on a case-by-case basis)
Rates : (specify: hourly, daily, or otherwise)
Remarks :
Profile :

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