Membership Application Form

Your membership will keep you in touch with what is happening at NMRC by providing you with "first news" on all new programs and up coming workshops. You will also receive our quarterly newsletter, News & Views and a membership card. This membership is renewable at 12 month intervals.

Please fill in the information below and print it out and either fax it to 250.716.1557 or email it to info@nanaimomen.com. * indicates necessary information. When we receive your membership application we will contact you about payment options.

Today's date: -- mm/dd/yy

Please provide the following contact information:

*First Name

*Last Name

*Title

Organization

*Street Address

Address (cont.)

*City

*State/Province

*Zip/Postal Code

*Country

Work Phone

*Home Phone

FAX

*E-mail

URL

Do you belong to another organization working with similar issues?

Yes No

Name of Organization?

Is this a new membership?

Yes No

By clicking the box below I agree to the principles stated in the Constitution of the Nanaimo Men's Resource Centre, a Registered Society under the provisions of the Society Act of British Columbia. I further agree to comply with the Constitution & Bylaws of this Society as may be amended from time to time pursuant to the by-laws.

I agree

Personal Annual Membership Fee:

$10.00

Corporate Annual Membership Fee:

$100.00

*First Name
*Last Name
*Title
Organization
*Street Address
Address (cont.)
*City
*State/Province
*Zip/Postal Code
*Country
Work Phone
*Home Phone
FAX
*E-mail
URL

Membership Application Form

Revised: May 28, 2008