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

(Please print out this form and send it with fee to 348 Ross Avenue Winnipeg MB R3A0L4)