(Please PRINT Clearly)

Surname

Given Names  (underline preferred name)

 

Address:

  

City

 Prov

 

Postal Code

  

Country

  

Telephone                                                 

Telephone 

 Fax

(Home)                                                      (

Other)

 

Degree(s)/Diploma(s)/Certificates  (plea

se complete only if you wish)

 

Current Occupation(s)

  

Signature

 Date (dd/mm/yyyy)

 

Fees

CDN $90.00

Payment by    Cheque   (payable to: CFUW Vernon)

Cash

© CFUW Vernon 2023