VIPMA Membership Application

VIPMA Memberships are accepted January 01 through to September 30 of the same calendar year.  After September – memberships are not accepted as the Placer season ends shortly after.

FMC’s must be current

First Name *

Last Name *

Email Address *

Phone *

Membership Applying for *Regular Membership ($113.60)Associate Membership ($56.60)

Placer Tenure Number

Who is your Sponsor?

FMC Number *

FMC Expiration Date *

Street Address *

Apartment, Suite etc...

City *

ZIP/Postal Code *0 / 10

Country *

State/Province *

Emergency Contact Person

Emergency Contact Phone

Are you joining for insurance to prospect on CRD or Timberwest Land?YesNo

Date of Attended VIPMA Meeting *

Do you have a claim in the CRD? *YesNo

Consent to VIPMA facilitating entry into Private Lands using personal information *

Yes

Do you have a person to vouch for you?YesNo

Voucher's Name

Vouchers Phone

Membership Fees for 2023 - Regular Membership $113.60 | Associate Membership $56.60

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