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MEMBERSHIP FORM / FORMULAIRE D’ADHÉSION DES MEMBRES

CIRCLE / ENCERCLÉ : NEW MEMBER / RENEWAL - NOUVEAU MEMBRE / RENOUVELLEMENT

NAME/NOM: ______________________________________________________

ADDRESS/ADRESSE: _________________________________________________________

PHONE/TÉLÉPHONE:
HOME/MAISON : _______________________ OFFICE/BUREAU: _______________________

FAX/TÉLÉCOPIEUR:
HOME/MAISON: _______________________ OFFICE/BUREAU: _______________________

E-MAIL/COURRIEL:
HOME/MAISON:_________________________ OFFICE/BUREAU: ______________________

DATE OF BIRTH/DATE DE NAISSANCE:
DAY/DATE:__________ MONTH/MOIS:__________________ YEAR/ANNEE:____________

SIGNATURE:____________________________________ DATE: ______________________

FEES/FRAIS D’ADHÉSION: 1 year/an $30.00 ___ 2 years/ans $60.00___
Make Cheque payable to: ACU

Complete and mail to:/Remplir et poster à :

Michel Careau
ACU
7, rue de la Loire
Gatineau, QC
J8Z 3L1

micheldelaloire@can.rogers.com