Membership Registration Form

Please indicate the category of interest and complete the personal information and gift membership information sections, as applicable.

	Basic*	Plus*
Individual	$26.50____	$53.00____
Household	$53.00____	$84.80____
Associate	$42.40____
Senior	$21.20____
Grandparent	$42.40____
Caregiver	$42.40____

*Includes GST
Please call the Membership Office to register for Group memberships.

Personal Information

New member ___ Renewing member ___
Membership card no. ________ Gift membership ___

Name ____________________________________________
Full name as it will appear on membership card

Name _____________________________________________
Full name of the second cardholder
(excluding Individual categories)

Address _______________________________

City_________________________  Province/State_______

Postal Code/Zip code___________________________

Telephone (home) ______________ (work) ______________

E-mail: _______________________________

The Membership Office will periodically send you electronic mailings with important information so you don't miss out on any of the fun or benefits of being a member!

Correspondance: English___ French___

Gift Membership Information

Purchaser's name ________________________________

Address ________________________

City ______________________ Province/State ___________

Postal code/Zip code __________________

Telephone (home) ______________ (work) ______________

Gift membership package should be mailed to:

___ Purchaser (details supplied directly above)
___ Recipient(s) (details supplied in personal information section)

Method of payment

Total $_______($CDN)

___ Cheque enclosed
(made payable to Canada Science and Technology Museum Corporation)

____ Visa   ____ MasterCard

____________________    ___/___
Card number no.               Expiry date

Cardholder's name ____________________________________

Signature ___________________________________________

© 2006 Canada Agriculture Museum