Manitoba Association Of Personal Care Home Social Workers
Box 2591 Station Main, Winnipeg Manitoba, R3C 4B3
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APPLICATION FOR MEMBERSHIP (NEW)
Name: ____________________________________________________
Employing Agency: _________________________________________
Address: _____________________
Phone (W): _____________
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(H): ____________
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Fax: __________________
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Email: _________________
Job Title: ____________________________________________
Education: ___________________________________________
Where Acquired: ______________________________________
Graduation Year(s): _________________________
*************Please attach copy of degree(s)***************
Brief description of the nature of your present work, and related experience:
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What benefits do you expect to derive from your membership in the association?
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Signature: ______________________
Date: __________________________
Please enclose cheque for the amount of __________ payable to MAPCHSW.
Your money will be reimbursed if your application is not accepted.
For Acceptance Committee/Chair to complete:
Date Approved:_________________ Date Secretary Notified: _______________
Fee: _________ Paid:_________ Membership Coord. Notified: ___________
Date cheque given to Financial Chair: ______________________
Form revised: June 13, 2003