Winnipeg Robert Burns Club #197
Application for Membership
Prefix_________ First Name ____________________ Initials _____ Last Name ______________________
Home Address____________________________________________________________________
City/Town ____________________________ Prov. ____________
Postal Code _____________________
Preferred Email ______________________________________________________________
Home Telephone ___________________________ Cell _________________________________
CONSENT
___ I consent to the above information being listed in the Club’s published
membership roster
___I consent to only my Name only being listed in the Club’s published
membership roster
__ I consent to receive email from the Winnipeg Robert Burns Club
Payment
___ By cheque
Please include a cheque in the amount of $8.00 payable to “The Winnipeg Robert Burns Club”
Please mail your completed application with your cheque payment to:
Winnipeg Robert Burns Club
c/o 461 Shelley St Winnipeg MB
R3K 1E9
Date _________________________________
Signature of Applicant_________________________________________________ |
