Membership Form - Backus

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Tyrconnell Heritage Society
Privileges of Membership
Charitable Tax Receipt for the full amount of your membership and/or donation.
Membership Card and Vote at the Annual General Meeting.
Recognition of your support on our website.
All charitable tax receipts are sent in February of the following year.
Tyrconnell Heritage Society
Privileges of Membership
Charitable Tax Receipt for the full amount of your membership and/or donation.
Membership Card and Vote at the Annual General Meeting.
Recognition of your support on our website.
All charitable tax receipts are sent in February of the following year.
Choose one of the following:
___ Lifetime Individual Membership - $250.00
___ Annual Individual Membership - $30.00
___ Annual Couple’s Membership - $35.00
___ Annual Family Membership - $40.00
___ Annual Organization Membership - $45.00
___ Annual Business/Corporate Membership - $75.00
Choose one of the following:
___ Lifetime Individual Membership - $250.00
___ Annual Individual Membership - $30.00
___ Annual Couple’s Membership - $35.00
___ Annual Family Membership - $40.00
___ Annual Organization Membership - $45.00
___ Annual Business/Corporate Membership - $75.00
___I would like to add a donation in the amount of $_________.
___I would like to add a donation in the amount of $_________.
Name of Member: ________________________________
Name of Member: ________________________________
If this is a family or couple’s membership please list spouse and/or
any children under age of 18:
If this is a family or couple’s membership please list spouse and/or
any children under age of 18:
_________________________________________________
Name of Organization of Business: ____________________
Mailing Address:_________________________________
City: _______________________ Postal Code: __________
Phone:__________________________________________
E-mail: _________________________________________
_________________________________________________
Name of Organization of Business: ____________________
Mailing Address:_________________________________
City: _______________________ Postal Code: __________
Phone:__________________________________________
E-mail: _________________________________________
Please make all cheques payable to the Tyrconnell Heritage Society and
return to:
Tyrconnell Heritage Society, P.O. Box 26, 29424 Lakeview Line,
Wallacetown, ON, N0L 2M0
We thank you for your support and generosity.
519-762-3072 info@backuspagehouse.ca
Please make all cheques payable to the Tyrconnell Heritage Society and
return to:
Tyrconnell Heritage Society, P.O. Box 26, 29424 Lakeview Line,
Wallacetown, ON, N0L 2M0
We thank you for your support and generosity.
519-762-3072 info@backuspagehouse.ca
www.backuspagehouse.ca
We also accept cash, Visa, Master Card, and American Express.
www.backuspagehouse.ca
We also accept cash, Visa, Master Card, and American Express.
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