Last Name: First Name:
Name of Spouse:
Home Address with Postal Code:
Phone (Home): (Cell):
Email Address:
Membership Type: (General / Associate) (Please circle one)
Family ($50.00) Single ($ 30.00)
Signature: Date:
Membership is valid from
April,01 to March,31 of every year
For Office Use Only:
Membership No.
General Secretary
President
(Please print out this form and send it with fee to 348 Ross Avenue Winnipeg MB R3A0L4)