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Broker's Details

Broker Name *
Street *
City *
Province *
Postal Code *
Months At Present Address *
Official Email Address *
Phone Number *
Fax *
Website *

Broker Contact Details

First Name *
Last Name *
Contact Phone Number *
Contact Email Address *
Position at Broker *

Online Advertiser Information

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Account Information

Username *
Password *
Confirm Password *

Membership Selction

Hours of Operation

Payment Information

Payment Method *

Additional Information

As a member of CLC your brokership will automatically qualify for preferred credit card processing rates.
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Additional note

I understand that by submitting this form I am authorizing credit linx canada to create an account for the brokership I represent. I understand that I will be billed based on the package and options that I have selected. I also understand that my selected payment method will be used to collect my CLC membership fees as well as all future charges billed to my account. I further certify that I have the right to create this account on behalf of the brokership I represent.