Online Membership Application Form

1. Select the Membership you are applying for:

Single $24	*Country Single $12	*Pension Single $12
Family $36	*Country Family $24	*Pension Family $24

2. Principal Member Information:
First Name
Surname
Home Phone
Mobile Phone
Birth Town	(Town & Prov/State)
Email Address
Birth Date	(dd-mmm-yyyy)
	Please include your birth date for event planning. You can use the Birthday Privacy option below to keep it private.

3. Home Address:
Number & Street
Suburb
State
Postcode

4. Communications:
Once approved, you will automatically receive various club emails (such as Newsletters). Do you wish to receive any other Canadian related emails that may be passed on to the club?
Select One:	Club emails only	Club & Canadian emails

All Single Memberships continue to Step 7 - Privacy Options

5. Partner Information:
First Name
Surname
Mobile Phone
Birth Town	(Town & Prov/State)
Birth Date	(dd-mmm-yyyy)
Email Address

6. Children Information:
Include details of your children that live with you either full time or part time.
Name	Place of Birth	Birthdate (dd-mmm-yyyy)






7. Privacy Options:
The Canada Club of Victoria Inc respects your privacy. We will not sell or trade information we gain from this form - it will only be used for Club purposes only! We even allow you select which information is shared with fellow club members with the following Privacy Options. You decided which home information is shared with fellow club members in the club directory. Select 'Share' or 'Private' for each of the following :

Address:	Share	Private
Email:	Share	Private
Phone (home & mobile):	Share	Private

Earlier on this form, birth dates of the Primary Applicant and partner were requested. We ask that you supply them to allow us to better plan events. However, these birth dates can also appear in the club newsletter. Please select one of the following options with regards to the birth dates.

Adult Birthday(s):	Planning & Newsletter	Planning Only

8. Joining Condition:
Please select one of the following conditions about the Primary applicant:


9. How Did You Find Out About The Club?


10. Terms And Conditions
Select 'Agree' or 'Disagree' for each of the following:

Any personal information of club members or administrators gained through the club will be used for personal use only and will not be used in any form of marketing or solicitation.

Your agreement:	Agree	Disagree

You will adhere to the rules and regulations as set down in the Constitution and by-laws of the Canada Club of Victoria. Click here to view the Constitution

Your agreement:	Agree	Disagree

11. Membership Submission

Your Membership Application will be processed once we have received both your application form and your payment. Once you click the 'Submit Now' button below, we will have your application - all we will need is your payment. You can make your payment in one of two ways:

Electronic Bank Transfer: B.S.B. - 063882 A/C # - 10161260 Put your name in the note field		Cheque: -make your cheque out to 'Canada Club of Victoria’ -Send it to: Canada Club Of Victoria PO Box 477 Glen Waverly VIC 3150

Which way will you be submitting your payment: