Regional Council Observer Registration Form – Jan 30

Name *

First

Last

Address *

City *

Province *

Postal Code *

Telephone (H) *

Telephone (W)

Component *

Local

PSAC ID *

Email *

Member of the National Board of Directors

If ‘no’, please fill local information below.

Name of Local President, Local Executive member or committee chair contact

E-mail of Local President, Local Executive member or committee chair contact

Phone number of Local President, Local Executive member or committee chair contact

Do you self-identify as a member with a disability

Do you require documentation in alternative media? Please specify

If not indicated above, please list of your special requirements so that we can properly accommodate your needs