Vishva Shakti Durga Mandir Association
MEMBERSHIP for the period of January 1st, 2012 to December 31st, 2012
New Members (Please provide all information below)
Renewal (Please provide your full name and updated information, if any)
CHEQUE
CASH
Annual Family Membership $ 51.00
Annual Single Membership $ 31.00
Life Membership (Family) $ 501.00
Life Membership (Single) $ 301.00
* Please make the cheque payable to
Vishva Shakti Durga Mandir Association (VSDMA)
*
Last Name:
*
First Name:
Spouse Name:
Phone #:
*
Address:
City:
Province/ Postal Code:
*
Email Address:
Child 1 Name:
Age (in yrs):
Child 2 Name:
Age (in yrs):
Child 3 Name:
Age (in yrs):
Date:
19/5/2012
(dd/mm/yyyy)
Member's Signature: __________________________
Thank you for membership and support to Vishva Shakti Durga Mandir Association
Received and Approved by:
(for Vishva Shakti Durga Mandir Association)
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