NAME:

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ADDRESS:

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CITY:

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PROVINCE:

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POSTAL CODE:

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PHONE NUMBER (HOME):

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PHONE NUMBER (WORK):

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E-Mail

Special interest

ENCLOSED (cheques/money orders only): $

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FEES

$20 Single, $30 Family.

All donations (including the basic membership fee) are eligible for a charitable receipt.

Canadian Charitable Organization Registration Number: BN 10820 4025 RR0001