open the membership renewal form

2015 CERTIFICATION DUES RENEWAL FORM
To renew on-line, go to http://www.search.eocp.ca and the information we have on file for you will be displayed on the screen. Please
make the necessary changes. If you choose not to renew online, please complete ALL sections of this form and mail it to our office
along with your cheque or credit card number. If your employer pays, complete this form and give it to your employer for inclusion
with their payment.
Mr./Ms. ____________________________________________________
Certification No. _________
Certificates Held _____________________________________
(Last Name, First Name, Middle Initial)
(List all certificates held)
Home Address ________________________________________ City _______________________________ Province/Territory ______ Postal Code _________________
Home Phone (____) ________________ Cell Phone (____) __________________ Work Phone (____) ________________ Fax (____) __________________
E-Mail _______________________________________ Date of Birth: _______________________
Currently:
Self Employed:
Unemployed:
dd-mm-yyyy
Employed:
Retired:
If employed, please complete employer information and table below.
Principal Employer ________________________________________
Do you authorize the EOCP to provide your personal information necessary for your
employer to carry out updates and/or corrections on your behalf? Yes
No
Department _____________________________________
Street_____________________________________
Voluntary Information – Are you a member of a First Nation? Yes
No
City ______________________ Province______ Postal Code_____
If so, what is your Band Number?_______
Certificates
% of
Facility
Employment
Employment
Held *
Time **
Job Title
Number
Facility Name
Facility Owner
Start Date
End Date
If there are not enough lines above, please use the back of the form.
* List each active certificate by type (Do not include CH). ** Indicate the percentage of your work time you use each of the certificates you hold at the
facilities you work at. If your work ended at a facility in the past year, please indicate the date that your work ended in the appropriate column.
GST No. 89383 7971 RT0001
For the year ending Dec 31, 2015
Dues Calculation Examples:
1) Operator Certified as WD-I &
For Certificates that include one or more of:
- WT, WD, WWC, MWWT, IWWT
$70.00
WT-OIT –
Dues $70.00 Visa or M/C #: ___________________________
2) Operator Certified as SWS –
For Certificates held that ONLY include:
Dues $60.00 Expiry Date:
___________________________
- SWS, SWWS, and/or BWD
$60.00
mm/yyyy
3) Operator Certified as WT-I &
Late fee (after Mar 31, 2015)
$10.00
SWS–
Dues $70.00 Name on Card: ___________________________
Reinstatement
Level OIT-IV $80.00
2014
Plus Late Fees, Reinstatement Fees &
Fees
SWS, SWWS, BWD $70.00
Tax.
Level OIT-IV $80.00
NOTE: IF ANNUAL DUES ARE NOT RECEIVED
2013
SWS, SWWS, BWD $70.00
BY MARCH 31, 2015, AN OPERATOR IS
NOT IN GOOD STANDING
For Office Use Only
Level OIT-IV $80.00
2012
SWS, SWWS, BWD $70.00
IF ANNUAL DUES ARE IN ARREARS
Date Received
SUB TOTAL
FOR 3 YEARS, YOUR CERTIFICATION
Date Entered
PLUS 5% GST
WILL LAPSE
TOTAL PAYABLE & ENCLOSED
CC Approval
Mail completed form and cheque or money order to: ENVIRONMENTAL OPERATORS CERTIFICATION PROGRAM
201 - 3833 Henning Drive, Burnaby, B.C. V5C 6N5
Ph: (604) 874-4784 Toll Free 1-866-552-EOCP(3627) Fax: (604) 874-4794 E-mail: [email protected]

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