Agent Membership (Incl GST) Please fill out the following registration information: Company Name*Postal Address* Street Address City State ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Name* First Last Email* Phone*Accounts Dept Email Address* Nominee 1 Name(One only for Agent, Individual or Supplier/Partner Membership) Nominee 1 Email Job Title Nominee 1*Nominee 2 Name(Corporate or Platinum Membership only)Nominee 2 Email Job Title Nominee 2Nominee 3 Name(Corporate or Platinum Membership only)Nominee 3 Email Job Title Nominee 3Nominee 4 NameNominee 4 Email Job Title Nominee 4Nominee 5 NameNominee 5 Email Job Title Nominee 5Profile*Brief explanation of business activitiesFunction*Practitioner/Vendor/Vendor & Practitioner/Other - please specifyIndustry*Please SelectBanking/Insurance/Finance/Credit UnionBrewery/Liquor Retail/Wine ClubContact Centre Suppliers/Computers/SoftwareEquipment/Furniture/FittingsCharityChemical/Cosmetic/PharmaceuticalGovernment/Semi Government/Essential ServicesMedical/Health FundPublishing/MediaRecruitmentRetail/WholesaleService/Consultant/ResearchTelecommunicationsTourism/TravelTraining-specify as Provider/Outsource/In-houseTransport/CourierSize of Contact Centre*Number of Locations*Type Of Contact Centre*Please selectInboundOutboundBlendedDuties of Contact Centre*Please selectInbound:BookingsCustomer ServiceDirect ResponseE-CommerceHelpdeskOtherOutbound:Account ManagementCredit ControlE-CommerceFundraisingLead GenerationTelemarketingTelesalesPlease CategorisePrivacy Information*YesNoI acknowledge and give permission for CCiNZ to publish for marketing purposes photo’s/content with your name/organisation Contact Centre Location*Referred by/Heard about CCiNZ from:*Pay by Invoice if joining outside membership yearMembership year commences 30th June so please select Payment Type*Select Payment TypeSecure Online Credit Card PaymentPay by InvoiceHow would you like to pay?CAPTCHA