Agent Membership (Incl GST)

Please fill out the following registration information:

Company Name*
Postal Address*
Street Address City State ZIP / Postal Code 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 2
Nominee 3 Name
(Corporate or Platinum Membership only)
Nominee 3 Email
Job Title Nominee 3
Nominee 4 Name
Nominee 4 Email
Job Title Nominee 4
Nominee 5 Name
Nominee 5 Email
Job Title Nominee 5
Profile*
Brief explanation of business activities
Function*
Practitioner/Vendor/Vendor & Practitioner/Other - please specify
Industry*
Size of Contact Centre*
Number of Locations*
Type Of Contact Centre*
Duties of Contact Centre*
Please Categorise
Privacy Information*
- Yes
- No
I 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 year
Membership year commences 30th June so please select
Payment Type*
How would you like to pay?
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