STAC APPLICATION/ CWTA ASSOCIATE 2021/2022 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 Phone*Website* Twitter Primary ContactName* First Last Title* Phone*Email* Consent* I consent to my basic coordinates, as above, to be included on the “STAC Primary Contact List” and grant permission for STAC to share that information with other Primary Contacts that have also consented (see "Terms of STAC Annual Certification" for further information).*Secondary ContactName First Last Title PhoneEmail Marketing and Communications ContactName First Last Title PhoneEmail Accounting ContactName First Last Title PhoneEmail Primary Safety ContactName First Last Title PhoneEmail Brief Company ProfileCompany ProfileFee ScheduleCompanies with:* 5 or less employees* ($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 industriesAnnual fee based on Schedule:(plus applicable GST/HST)Annual flat fee for Suppliers**: $1,500 (plus applicable GST/HST) **See "Terms of STAC Annual Certification" for Supplier eligibilityYou must certify your application with one of the following statements:* By checking this box, I certify that only the company listed on page 1 of this form is the applicant and holds the associate membership. The employees as reported, reflect the number of employees of the company, or the company is a Supplier and pays an annual flat rate. By checking this box, I certify that in addition to the company listed on page 1, the following subsidiaries and their respective employees, have been included in the employee count and is reflected in the annual fees payable. STAC Membership benefits are only extended to subsidiaries reported below. Companies who want unique membership listings for subsidiaries need to submit a separate application for each company. 1.* 2. 3. Consent* I have read and understood the "Terms of the STAC Annual Certification", and have accurately reported the annual fee to the best of my knowledge and with the information available at the time of submission.*Your Name* First Last Date* 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.