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APPLICATION FOR ACTIVE MEMBERSHIP


Western Fallers Association
2003 Cinnabar Drive, Nanaimo, B.C. V9X 1B3
Phone: (250)  754-3908      Fax: (250)  638-8729



PLEASE PRINT CLEARLY

Name in full:        _____________________________________________

Company name:  _____________________________________________
(If Applicable)

Mailing Address:  _____________________________________________

                           _____________________________________________

Phone Number:    ____________________________

Fax Number:       ____________________________

E-Mail:                ____________________________


In order to remain a voting member, your dues must be kept up to date annually.



___________________________________
Applicant's Signature

___________________________________
Date

All cheques to be made out to the Western Fallers Association


_____________________________________________________________________________________________________________________________________________________________________________________________________________ DO NOT WRITE IN THIS SPACE - FOR OFFICE USE ONLY


Annual dues of $107.00 received in full                            ____________________________________
W.F.A. Authorized Signature
____________________________________
Date