Fee Form Contact Information Company Name * Date (MM/DD/YYYY) * Your Name * Contact Email * Billing Location Address * City * Postal Code * Province * ABBCMBNBNLNSNTNUONPEQCSKYT Primary Phone Number * Previous Year WCB Assessable Payroll * Industry Code(s) * Please Note: Minimum fee is $100.00 + GST, Maximum fee is $10,000 + GST Previous Year WCB Assessable Payroll Yearly Rate Base Membership Fee GST (5%) Total Fees Due Membership fees are based on a January to December term. Any membership after February will be pro-rated. Pro-rate membership Month Membership Begins - None -JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Total Fees Due I am authorized to provide MHSA access to the employers' WCB estimated payroll for membership invoicing purposes. * I am authorized to provide MHSA access to the employers' WCB estimated payroll for membership invoicing purposes. By submitting this application you are agreeing to receive electronic messages from the Manufacturers’ Health & Safety Association MHSA. At any time you may unsubscribe if you no longer wish to receive our emails.