MEMBERSHIP APPLICATION
Please print then fill out this application form or simply CALL US at 571-6788 and we can do this over the phone.
All you need do, is send in your membership fee.

NAME ___________________________________________

ORGANIZATION __________________________________

ADDRESS ________________________________________

CITY _______________________ POSTAL CODE ______

PHONE _____________________ FAX ________________

E-MAIL _____________________ DATE _______________

First Time Membership ____Yes ____

No Renewing Membership ____ Yes ____ No

Fee Structure

Individual $5.00 / year $10.00 / 3 years

Organization $25.00 / year $50.00 / 3 years

If our membership fees are prohibitive, simply contact us at 894-8350

DONATION

I would like to make a donation in the amount of $ ___________

Mastercard # ______________________ Expiry Date ____________

Cheques payable to:

Independent Living Centre of Waterloo Region
127 Victoria Street South, Suite 201,
Kitchener, Ontario
N2G 2B4

Charitable Receipts issued for all donations over $10

Charitable #10750-5356-RR001

AMOUNT ENCLOSED (TOTAL) $______________

SIGNED ____________________________________

Thank you for your support!