Application Form
This form is to be completed by the Treasurer. Send directly to the BWOQ office, along with your payment for the Circle Life Membership fee and Circle Life pin (if required). Please make cheque payable to Baptist Women of Ontario and Quebec or pay by credit card.
BWOQ OFFICE: 100 - 304 The East Mall, Etobicoke, ON M9B 6E2
Please Print
RECIPIENT OF THE BWOQ CIRCLE LIFE MEMBERSHIP:
NAME______________________________________________________
PRESENTED BY:
NAME OFCHURCH___________________________________________________
CITY OR TOWN_________________________________
PRESENTATION DATE, if known: __________________________
DO YOU REQUIRE A CIRCLE LIFE MEMBERSHIP PIN? __ Yes __ No
SEND CERTIFICATE AND PIN TO:
NAME__________________________________________________
MAILING ADDRESS______________________________________________
AMOUNT ENCLOSED FOR PIN(S) @ $5.50 EACH: _________
AMOUNT ENCLOSED FOR MEMBERSHIP(S) @ $35.00 EACH: _________
TOTAL _________
PAYMENT BY __Cheque __Money order
Credit card __VISA _MASTERCARD __AMERICAN EXPRESS
Card number___________________________________ EXPIRY ______________
Name on card __________________________________
For Office Use:
Pin ( ) $______________ Received __________________ Issued____ __________