CBIAC Request Form

CBIAC Mailing List Request Form

The CBIAC is establishing an email address list to provide the CBD community with timely announcements and pertinent information from the CBIAC. We are also screening our CBIAC Newsletter mailing list database for incomplete entries and outdated organization names, office symbols, locations, etc.

If you are eligible for CBIAC services, and would like to be included on our electronic mailing list and/or continue to receive the CBIAC Newsletter in hardcopy format (electronic copies are posted on our web site), please complete and submit this form.

Please provide the following contact information (Bold information is required):

Do you want to be included on our email list? Yes No

Do you want to receive the CBIAC newsletter? Yes No

Title

First name

Last name

Organization

Office Symbol

Street address

Address line 2

City

State/Province

Zip/Postal code

Country

Work Phone

FAX

E-mail

Thank you.

Do you want to be included on our email list?		Yes		No
Do you want to receive the CBIAC newsletter?		Yes		No

Title
First name
Last name
Organization
Office Symbol
Street address
Address line 2
City
State/Province
Zip/Postal code
Country
Work Phone
FAX
E-mail