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Membership Application Form |
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 $40.00/year.
Note: Memberships in good standing are subject to verification of valid payment. Fees are not refundable after 3 banking days.
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