CFUW / SARNIA LAMBTON

ANNUAL MEMBERSHIP APPLICATION FORM

2010-2011

If you are a returning member with no changes, please fill in your name.

If you have any changes to make from last year, please fill in just the changes below.

NAME: __________________________________________________________________

ADDRESS: _______________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

PHONE: Residence:___________________ Business: _______________________

Email: ____________________________________________________________________

DEGREES: ________________________________________________________________

UNIVERSITY (UNIVERSITIES): ______________________________________________

_________________________________________________________________________

MEMBERSHIP FEE: $90.00 (All members) Date sent: ______________

A $25.00 donation to the Bursary Fund is suggested in lieu of an annual fundraising event.

An official receipt will be issued.

Please mail your form and cheque to:

Heather Ashe

W51 - 1500 Venetian Blvd., Point Edward, Ontario N7T 7W4

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