Business Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Contact *

First Name

Last Name

Phone *

(###)

###

####

Confirmation *

Yes, I understand that, once certified, I will need to complete an annual recertification form confirming I am still meeting the program requirements in order to maintain my living wage employer status.

Why do your feel it is important to pay a living wage? (Check all that apply)

To increase employee retention

To decrease the number of sick days and reduce benefit costs

For positive brand association and to be seen as an ethical employer

To attract desirable, qualified recruits

To increase productivity

Feel obligated to do so

Other (please explain below)

Would you like to receive any promotional items?

Yes

No

Would you like a plaque for display at a physical location?

Yes

No

Optional items

Yes, I agree to allow my organization’s name to be used on the Alberta Living Wage Network and in potential media and public events. (Optional)

Yes, I would like to offer my support to other employers in the application process. (Optional)

Annual Employer Fees (to be paid upon joining)

Private Sector - fewer than 10 employees - $100

Private Sector - 11-50 employees - $200

Private Sector - 51-250 employees - $400

Private Sector - 251-500 employees - $800

Private Sector - 500+ employees - $1000

Public or Non-Profit - fewer than 10 employees - $50

Public or Non-Profit - 11-50 employees - $100

Public or Non-Profit - 51-250 employees - $200

Public or Non-Profit - 251+ employees - $400

Signature (spell out your complete name as acceptance) *

First Name

Last Name

Date

MM

DD

YYYY