| CANADIAN INJURED WORKERS SOCIETY MEMBERSHIP
APPLICATION
Mission Statement : To promote fair and
equitable compensation for injured workers in Canada, to address the
mistreatment of injured workers and to voice the common concerns of injured
workers across Canada.
Membership fees are $20 for an individual, $25
for a family residing at the same address, and $80 for an Associate
Membership for groups.
Please return your application and copies of
two pieces of identification, such as Driver's Licence, Medicare, or Birth
Certificate to or fax to removed for archive or mail to removed for archive (Proof of injured worker status is only required if you
want to serve the society in different capacities.)
Payments can be made via PAYPAL from the CIWS
website or by Email Transfer to or send CHEQUE payable to the
Canadian Injured Workers Society at the above address.
For more information email
Applicant's Name: (PLEASE PRINT)
__________________________________________________________________ _
Name of other Applicants living at the same
address: (for family membership) (PLEASE PRINT)
_____________________________________________________________________________________
Address:
_____________________________________________________________________________
City: _____________________________
Province: _______________ Postal Code: ______________
Phone: _____________________________
E-mail: __________________________________________
Fax: _____________________________ Web
site (if applicable): _______________________________
Province of Compensation Claim (if
applicable)_________________ Claim No.__________________
Employer at time of Injury (if
applicable): __________________________________________________
If this is not your claim, what is your
relationship to the claimant (ie spouse) ____________________
Are you an Advocate for Injured Workers?
________________________________________________
If so, do you receive any form of remuneration
for your work as an Advocate? ________________
Please read this agreement carefully before you
register. By signing below: I agree that I have read the
by-laws of the Canadian Injured Workers Society, and that I
agree to abide by them. I am not in a conflict of interest regarding the best
interests of injured workers or the goals of the society. I hereby also declare
I will never reveal information from these forums to any Worker's Compensation
Agency or any other agency or anyone who will divulge information gathered here
to a Worker's Compensation Agency. I agree that the webmaster, President or
elected officials of the Canadian Injured Workers Society have the right to
remove, edit, move or close any topic at any time should they see fit from or
on the CIWS web site. I agree to abide by the forum rules as posted on the main
CIWS web site. I agree with the society's mission statement as stated above and
I agree with the principles within it.
Signature:
______________________________________
Date:
___________________________________________
Additional Family Member's Signatures:
__________________________________________________________________________________
++ Please note - Anyone who fabricates
information, including but not limited to a WCB Claim and claim number, will be
charged with fraud. No one may request admittance if they intend on sharing
someone else's private information without express written consent of that
member. Written shall mean hand written and include a signature. For further
information please refer to the CIWS
by-laws.
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