STAC APPLICATION/ CWTA ASSOCIATE 2019/2020 ANNUAL CERTIFICATION FORM The Structure Tower and Antenna Council (STAC) is administered by the Canadian Wireless Telecommunications Association (CWTA). Companies that join STAC also gain the credentials and privileges of a CWTA Associate, as defined in the association’s bylaws. Associates shall be limited to persons¹ who (a) are qualified to become Members; (b) do not wish to become Members; and (c) have applied to the Board of Directors to become, and who have been accepted by the Board of Directors as, Associates of the Corporation.¹ Person includes a corporation, a subsidiary or division thereof, a partnership, joint venture, an individual or other entity as the context may require.Company InformationCompany Name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Prime RepresentativeName* First Last Title*Phone*Email* Consent* I consent to my basic coordinates, as above, to be included on the “STAC Prime List” and grant permission for STAC to share that information with other Prime Representatives*Alternate RepresentativeName First Last TitlePhoneEmail Marketing and Communications ContactName First Last TitlePhoneEmail Accounting ContactName First Last TitlePhoneEmail Primary Safety RepresentativeName First Last TitlePhoneEmail Consent I consent to the basic coordinates of my company's Primary Safety Representative, as above, to be included on the "STAC Safety Associates List" and grant permission for STAC to share that information with other STAC member companies and their personnel. Note that this person can be the same as the Prime Representative.Brief Company ProfileCompany ProfileFee ScheduleCompanies with:* 5 or less employees* ($1,500) Supplier members ($1,500) 6 - 20 employees* ($2,500) 21 - 100 employees* ($4,000) 101 - 250 employees* ($5,000) 250+ employees* ($6,000) *Employees in the communications and tower industriesMy company has 20 or less employees and qualifies for the 15% COVID-19 Rate Reduction Yes Annual fees based on the schedule above:*(plus applicable GST/HST)Annual fees with COVID-19 Rate Reduction*(plus applicable GST/HST)Signature*Date* Date Format: MM slash DD slash YYYY The Structure, Tower and Antenna Council (STAC) and the Canadian Wireless Telecommunications Association (CWTA) use the information provided above to process the Associate’s registration. For further information on STAC please contact: Nicholas Kyonka ǀ Program Director - Structure, Tower and Antenna Council (STAC) Canadian Wireless Telecommunications Association (CWTA) 80 Elgin Street, Suite 300, Ottawa, ON K1P 6R2 (613) 233-4888 x227 ǀ Fax: (613) 233-2032 ǀ nkyonka@stacouncil.ca ǀ stacouncil.ca ǀ conseilspa.ca
