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Membership Application
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Media Club of Ottawa
Send this form directly to the Media Club of Ottawa
See instructions at the bottom of the form

 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 __ Associate - Associé ___ 

Non-Resident __ Student - Étudiant ____ 

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

How to

- Highlight the form and copy (CTRL c);  then click on the link above (Iris)  to open your email account. 

- Paste directly  into the body of the email, fill in and send.

This will constitutue your intention to join the Media Club of Ottawa.
We will contact you to finalize the procedure..