Canadian Federation of University Women

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					                          Canadian Federation of University Women
                              (a member of IFUW: International Federation of University Women)
                        331 Cooper Street Suite 502, Ottawa, Ontario CANADA K2P 0G5
                          Website: www.cfuw.org E-mail: memberservices@cfuw.org
                                  Phone: (613) 234-8252 Fax: (613) 234-8221

                   APPLICATION FOR MEMBERSHIP AS A MEMBER-AT-LARGE
                                  (Please PRINT Clearly)
Surname                                      Given Names                                                Membership #
                                                                                                                /12
                                              (underline preferred name)
Previous Surname(s)
(where applicable)
Address:
City                                                                             Province
Postal Code
Country
 Telephone                            Telephone                                       Fax
(Home)                               (Other)
 E-mail

Degree(s)/Diploma(s)
Year(s)
Institution(s)
Current Occupation(s)




I certify the above to be accurate. Signature                                                    Date (dd/mm/yyyy)

Fees
       CDN$60.00 (in Canada)                 Payment by Cheque               □Money Order                □
       US$70.00 (outside Canada)             (payable to: Canadian Federation of University Women)

                         Card Number (include additional Code if required)                           Expiry (mm/yy)
Credit Card
(visa or mastercard) Name of Card Holder

                         Authorization Code                                    Date Processed:
(Office use only)                                                                (dd/mm/yy)

				
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posted:9/29/2012
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