Spouse's Name:

Is this a single or double membership?:
Single
Double

Member Number:

Old Address (For verification):

New Address:

	Street:         

	City:           

	Province/State: 

	Postal Code:    

	Country (If other than Canada):
 
	

	

Telephone Number (Please include area code):

(  ) 

E-mail address:

Please make a selection below regarding your branch.

  I wish to stay in my current branch

  I wish to go to the branch closest to my new address

  I wish to belong to the  Branch.

Additional Comments: (Optional)