Membership / Donations

Please note the table below may not comply with the new Electoral law under Bill C-24 pertianing to Tax Credits:

Please renew or extend today on the following form:

First Name
Last Name
Address
City
Province
Postal
Home Phone *
E-mail *
Membership	New Renewal or Donation
If Membership Number of Years	1 2 3 4 5 X $10
Name on Credit Card
Credit Card Number
Credit Card type	VISA Master Card
Expiration Date	1 2 3 4 5 6 7 8 9 10 11 12 / 05 06 07 08 09 10 11 12 13 14 15
Total Amount	$10 $20 $30 $40 $50 - - Other $

Donations and membership forms can also be e-mailed to Wilmer Doerksen  or mailed to the following address:

P.O. Box 34070, RPO Westbrook, Calgary, AB T3C 3W2

Please print and include the following information:

MEMBERSHIP INFO
Name (Last, First): ___________________________ , _________________________________________

Home Address:_________________________________

Postal Code:____________________

Telephone: Home_____________________ Work______________________

Email Address: _____________________________

Membership: New:___ Renewal:___

Year(s): _______($10/year) Total Donation Amount: $200:__ $100:__ $50:__ Other Amount: _______

Please make cheques payable to: Conservative Party Calgary West

Mail to: P.O. Box 34070, RPO Westbrook, Calgary, AB T3C 3W2