VIPMA REGISTRATION

First Name

Street Address*

Province/state*

Phone*

FMC Number*

FMC Expiry Date

Membership Type

Regular MembershipAssociate Membership

Joining for insurance on CRD or Mosaic/Timberwest land?

YesNo

Last Name

Apartment/Suite

Postal Code/ZIP*

Emergency Contact

Placer Tenures

Date of attended VIPMA Meeting

Do you have a claim in the CRD?*

YesNo

Username*

Password*

Confirm Password*

E-mail Address

City*

Country

Emergency Contact Phone

Do you have someone to vouch for you?

YesNo

Voucher's name

Consent to VIPMA facilitating entry into Private Lands using Personal Information?*

Yes

Only fill in if you are not human