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CVA Member Application
1
Business Information
Company Name
Phone Number
Email Address
Website URL
Facebook URL
Business Description
2
Physical Address
Address
Unit / Suite
Ctiy
Province
Postal Code
Use Different Billing Address?
Billing Address
Unit / Suite
Ctiy
Province
Postal Code
3
Contact Information
First Name
Last Name
Title
Mobile Phone
Email Address
Contact Preference
Email
Phone
4
Membership Options
Basic Retail Membership (Vape shops Only): $100.00/month
Micro E-Liquid Manufacturer: $50.00/month
E-Liquid Manufacturer: $200.00/month
Major E-Liquid Manufacturer, Distributor or Hardware Manufacturer with or w/o stores: $500.00/month
Angel Supporter
: I would like to contribute more
per month
than above in the amount of :
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