Alliance Quebec Membership Form
Print out this page on your printer and mail it with your cheque or credit card information to:
Alliance Quebec
630 Rene Levesque West
Suite 2950
Montreal Qc.
H3B 1S6
or you can FAX this form with your credit card number directly to AQ's office's:
FAX # 514-875-7507
First Name:
Last Name:
Address:
City/Province:
Postal Code:
Telephone:
Fax:
E-Mail:
Names and Ages
For Family Memebership:
Chapter (if known):
Annual Membership fees: (circle one)
$15 Individual
$35 Family
$ 7 Youth (15-29 years)
$ 7 Senior (65 years plus)
I wish to make a donation in addition of: $
Payment
I enclose a personal cheque made out to Alliance Quebec
Please charge my VISA or MasterCard (circle)
Card Number:
Expiry Date:
Signature:
Date:
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