Safety Course Benefit Application Name(Required) First Last UA Card #(Required) Address(Required) 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Phone(Required)Choose All Courses That Apply(Required)Confined Space Entry and MonitorFall ProtectionMobile Elevated Work PlatformRespirator Fit TestCSOOtherOther; which course(s) did you complete Certification Card(Required) Drop files here or Select files Max. file size: 50 MB. Please upload proof of having passed the course you are applying forSafety Course Reciepts(Required) Drop files here or Select files Max. file size: 50 MB. Please upload proof of having paid for the course you are applying Payment Options(Required)–EFT (Direct Deposit)Mailout ChequePickup ChequeChoose payment option AboveOffice Use OnlyHiddenDues in Good Standing Yes No HiddenApproved Yes No HiddenIf declined, what is the reason? HiddenReviewed by: HiddenCoursesCSE:MEP:FP:FT:CSO:Other:HiddenAmount Electronic Funds Transfer (EFT) Authorization For Credit TransferOnly fill out the following section if requesting Direct Deposit.Request TypeInitial RequestChange RequestVOID ChequeAccepted file types: jpg, png, pdf, Max. file size: 50 MB.Please upload a picture of a void cheque with this requestName of Bank or Financial institution Address of Branch Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Branch NumberInstitution NumberAccount NumberConsent I consent to the following authorizationI authorize the Edmonton Pipe Trades Trust Fund and ATB to use the services of any member or affiliate of the Canadian Payments Association (CPA) in carrying out this authorization. I agree to be bound by the standards, rules, and practices of CPA as they may exist from time to time. I agree to give written notice of cancellation of this authorization to Edmonton Pipe Trades Educational Trust Fund and be bound by this authorization until the Edmonton Pipe Trades Educational Trust Fund has had reasonable time to act on the notice. Edmonton Pipe Trades Educational Trust Fund and/or ATB may terminate this authorization by providing me with ten (10) days’ notice. I undertake to inform Edmonton Pipe Trades Educational Trust Fund within five (5) days of any changes to branch, account, and institution number while this authorization is in effect.
