CANADIAN BAPTIST WOMEN’S
DOMINION LIFE MEMBERSHIP

Application Form


This form is to be completed by the Treasurer and forwarded to the Secretary-Treasurer of the Canadian Baptist Women’s Committee. Include a cheque or money order payable to the Canadian Baptist Women’s Committee.

SECRETARY-TREASURER CBW COMMITTEE
Starr Barrett
22 Willowlanding Court, Welland, ON L3C 7L7
905-734-3413
starrb@iaw.on.ca

Please Print

RECIPIENT OF THE DOMINION LIFE MEMBERSHIP:

NAME______________________________________________________

PRESENTED BY:

NAME OFCHURCH___________________________________________________

CITY OR TOWN_________________________________


PRESENTATION DATE, if known: __________________________

DO YOU REQUIRE A DOMINION LIFE MEMBERSHIP PIN? __ Yes __ No

SEND CERTIFICATE AND PIN TO:

NAME__________________________________________________

MAILING ADDRESS______________________________________________


AMOUNT ENCLOSED FOR PIN(S) @ $40.00 EACH: _________
AMOUNT ENCLOSED FOR MEMBERSHIP(S) @ $125.00 EACH: _________
TOTAL _________

PAYMENT BY __Cheque __Money Order



For Office Use:

Pin ( ) $______________ Received __________________ Issued____ __________

Updated September 29, 2006