Westmount Municipal Association
Membership Application / Renewal Form
This form may be used for membership applications or renewals paid by cheque or PayPal (please note that the PayPal option is not available for the time being).
* Indicates a required field in the form
I. Please provide us with your contact information
*First name
*Last name
Title (Dr. | Ms. | Mrs. | Mr.)
*Address (1)
Address (2)
*City
*Province
*Postal Code
Country
*Home Phone
(
)
-
Work Phone
(
)
-
extension
Fax
(
)
-
extension
*Email address
*Confirm Email
II. 2009/10 Membership Dues
*One of the following categories must be selected:
Individual
($10 )
Family
($15 )
Select one:
Renewal
New Member
III. 2009/10 Donation
Please consider making a donation (sorry, we can't give receipts for income tax purposes, as we are a political organization!)
Amount of donation: $25
$50
$100
Other
$
IV. Please provide payment information (the PayPal option is not available for the time being)
*I will pay by: Cheque
PayPal
If paying by cheque, please mail to:
Westmount Municipal Association
P.O. Box 653, Station Victoria
Westmount, QC H3Z 2Y7
Comments or special instructions: