Vishva Shakti Durga Mandir Association
 
MEMBERSHIP for the period of January 1st, 2017 to December 31st, 2017
New Members (Please provide all information below)
Renewal (Please provide your full name and updated information, if any)
 
  CHEQUE CASH
Annual Family Membership $ 51.00
Annual Single Membership $ 31.00
Life Membership (Family) $ 501.00
Life Membership (Single) $ 301.00
* Please make the cheque payable to Vishva Shakti Durga Mandir Association (VSDMA)
 
*Last Name: *First Name:
Spouse Name: Phone #:
*Address: City:
Province/ Postal Code: *Email Address:
Child 1 Name: Age (in yrs):
Child 2 Name: Age (in yrs):
Child 3 Name: Age (in yrs):
Date: 14/12/2017 (dd/mm/yyyy) Member's Signature: __________________________

 

Thank you for membership and support to Vishva Shakti Durga Mandir Association

Received and Approved by:

 
(for Vishva Shakti Durga Mandir Association)