Please print this form and send completed to the address below:


ALOUETTE ADDICTIONS SERVICES SOCIETY
MEMBERSHIP REGISTRATION

NAME: __________________________________ PHONE: ___________________________________

ADDRESS: ___________________________________________________________________________

CITY: ________________________________ POSTAL CODE: ____________________________

Membership Fee - $10.00 I would like to volunteer with Alouette Addictions Services o
I would like to offer a gift o $500 o $250 o $100 o $50 o $25 o Other $ _________________

Payment Method Cheque o MasterCard o VISA o

Card #__ __ __ __ / __ __ __ __ / __ __ __ __ / __ __ __ __ Exp. __/__

Cardholder's Name: ____________________________________________________________________

Signature: ____________________________________________________________________________

Alouette Addictions Services
22477 Lougheed Highway, Maple Ridge, BC V2X 2T8
Tel: 604-467-5179 Fax: 604-467-8592

Thank you. Receipts issued for donations over $10.00
Charitable Registration Number: 12948 9175 RR00001