Application Form - Formulaire d'adhésion

Personal Information - Coordonnées

Name of applicant - Nom du postulant: ____________________________

Address - Adresse: ____________________________________________

__________________________________________________________________

Phones - Téléphones: Home - à domicile: ____________________

Business - bureau: ________________ Fax: _______________________

E-mail address - courrier électronique: _____________________________

Employer - Employeur: _______________________________________

Job title or position - Occupation: _______________________________

Duties which qualify your membership. Responsabilités justifient acceptation:

________________________________________________________________________

Membership category. Catégorie pour laquelle vous faites la demande:

Active - Actif  $ 60  ___                                    

Non-Resident $ 25  ___                                     Student - Étudiant  $ 10 ____ 

Sponsors - Parrains (must be members of the club in good standing - membres en règle)

(PRINT) ___________________________________

Member Number #______________ Signature (Print) ________________________

Seconder - co-parrain - (PRINT) ________________________________

Member Number #______________ Signature (Print) ________________________

Signature of Applicant - Signature du postulant:(Print) _____________________________

Date of application - date de remise de l'adhésion: ___________________________

Note: Please copy and paste this form directly in an email to Iris
Thus, copy this page and then click on the link to open your email account. 
Then paste it into the body of the email, fill in and send.

This will constitutue your intention to join the Media Club of Ottawa.
You will be contacted to finalize the procedure..