Name: _____________________________________________

PLEASE INDICATE ANY CHANGES IN THE FOLLOWING INFORMATION

Address: ___________________________

City: __________________ Province: _________ Postal Code _________

Home Telephone No. _______________ Work Telephone No. _____________ Fax: __________________

E-mail address: ___________________________ (Important: Correspondence, including monthly newsletters, will be sent electronically to you)

Degree: University (or College) ______________ Qualification: _______________ Year: ______

Involvement

Are you willing to work on short -term projects? _____________________

Are you willing to serve on your CFUW Executive Committee next year? _______

What skills and interests would you like to bring to the Club? _________________________________

_______________________________________________________________________________

Membership Dues

Please pay at the opening Coffee Party on September 17th, 2010 or forward this form AND a cheque payable to CFUW Belleville & District to: Sandi Repic, 307 Frankford Rd., R.R. 1, Foxboro, ON K0K 2B0.

**If you wish to make a donation to the Scholarship Fund at this time, you may also include another cheque payable to CFUW Belleville & District Scholarship Trust Fund. $ ____________. Please note that a tax receipt will be received for this amount.

Additional Information

Would you like to have a ride to General Meetings? Yes ___ No ___

Could you provide another member with a ride to the General Meetings? Yes ___ No___

Privacy: All information you provide on this form will be held in strictest confidence for Club use only.