BCIT RETIREES' ASSOCIATION
Membership Application Form

Fill out the form below and then print it by clicking on the "Print" button on your toolbar

Date of application:

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

2010 2011 2012 2013

Surname:  Given Name:
eMail:
Street Address:
City:	Province: AB BC SK MB ON QC NB NS PE NL NT NU YT
Postal Code:
Home Phone:
Cell Phone:
FAX Number:
Spouse or partner's name:
Do you or you or spouse/partner receive superannuation from your employment at BCIT?
Yes	No
Fee: $10.00 per person per annum (Membership year - Jan 1 to Dec 31)
Amount paid: $  Cheque: Money order:
A receipt will be issued if requested below. I do not require a receipt: Please issue a receipt:
	Please mail completed form together with fee to:
	BCIT Retirees' Association 3700 Willingdon Avenue Burnaby, BC Canada V5G 3H2