Membership Application Form

12-months full and renewable membership,
including all family members at one address

Mandatory fields have an asterisk (*).

The following individual represents (self / company / family / other <describe>)_____________________

Title: (Dr) (Mr.) (Mrs.) (Miss) (Ms) (Rev.) (The Hon.) Salutation:_ Dear _______________________

*First name:___________________________ *Last name:___________________________

*Address line 1:________________________ Address line 2:_________________________

*City:________________________________ *Province:____ *Postal code:_____ ______

*Home phone:_________________________ Bus. phone:____________________________

E-mail:_______________________________ Other organizations:_____________________

(The above address is : Home - Business )

If family membership, how many members at the same address? ____

Profession:_____________________________ Company:______________________________

*Signature:_____________________________ *Date:______________________________

Current Hardware/Software/OS: _____________________________________________________

Skills: (Please circle: B=Beginner; I=Intermediate, A=Advanced) h/w - s/w?_______________ Don't know

Preferred start date: (YY/MM/DD)___/___/___. The fee is CAN $70.00/year.

Note: Memberships in good standing are subject to verification of valid payment. Fees are not refundable after 3 banking days.

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For Internal Club Use Only: Amount: $________

Interviewer / Processor (initials or membership number):__________ Was payment accepted? Yes | No

Cash ; Cheque #_______ ; Money Order _______ ; Renewal: J F M A M J J A S O N D

Treasury - DB -Mbshp-card Membership #_________ Verified:(initials)_________ __________

Please mail this filled form with your payment to:

Personal Computer Club of Toronto, 34 Ravenal Street, Toronto, ON M6N 3Y7