Provincial And Organizational Affiliates Membership Form

Membership Application:

Please check one
Provincial Affiliate Member: $300.00 Organizational Affiliate Member: $75.00

Application Information:

Organization Name *
Mailing Address
City *
Province *
Postal Code *
Facebook
Twitter
President’s Email Address *
Second Executive Board Officer’s Email Address *

Membership Status:

Renewal New

Language:

English French bilingual

Payment Method:

Cheque or Money Order (do not send cash in the mail)

Credit Card:

Visa MasterCard American Express
Card number:
Expiration Date:
Name on card:
Your Signature: