Membership
Membership Form 2009
( ) renewal ( ) new date ______/___/2009
Name ______________________________________________
Address _____________________________________Apt______
City _______________________ Postal Code_____________
Telephone (h)_____________________ (w) ___________________
(c) ____________________
E-mail ______________________________________________
May we e-mail newsletters and announcements to you? Y___ N___
Membership Fee
Individual or Family $10 *one vote per membership
Professional/Agency $20
Donation; I would like to make a donation of
___$1000 ___$500 ___$200 ___$100 ___$50 ___other
Payment Total payable (membership plus any donation) $________
Payment may be made by cash or cheque
Please make cheques payable to South Nepean Autism Centre
Mail to SNAC: 900 Greenbank Rd. Suite 530, Nepean, ON K2J 4P6
