MEMBERSHIP REGISTRATION FORM |
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| One
membership per form please.
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| MEMBER INFO: | ..................................................................................................................................... | ||||
| FIRST NAME | ..................................................................................................................................... | ||||
| LAST NAME | ..................................................................................................................................... | ||||
| ADDRESS | ..................................................................................................................................... | ||||
| CITY | ..................................................................................................................................... | ||||
| PHONE | ..................................................................................................................................... | ||||
| FAX | ...................................................................................................................................... | ||||
| ...................................................................................................................................... | |||||
| MEMBERSHIP TYPE (Circle one) |
( A ) ADULT |
( S ) SENIOR |
( Y ) YOUTH |
( J ) JUNIOR |
( C ) CHILD |
| If this is a gift please fill following information: | |||||
| SENDER INFO | ...................................................................................................................................... | ||||
| FIRST NAME | ...................................................................................................................................... | ||||
| LAST NAME | ...................................................................................................................................... | ||||
| ADDRESS | ...................................................................................................................................... | ||||
| CITY | ...................................................................................................................................... | ||||
| PHONE | ...................................................................................................................................... | ||||
| FAX | ..................................................................................................................................... | ||||
| ..................................................................................................................................... | |||||
| PAYMENT DETAILS: | |||||
| CASH | CHEQUE | VISA | |||
| Please make cheques payable to: PAPANACK PARK ZOO | |||||
| VISA INFORMATION: | |||||
| NAME ON VISA | ...................................................................................................................................... | ||||
| CARD NUMBER | ...................................................................................................................................... | ||||
| EXPIRY DATE | ...................................................................................................................................... | ||||
| SIGNATURE | ...................................................................................................................................... | ||||
Mail to: 150, County Road 19, Wendover, Ontario, K0A 3K0 |
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| E-mail: info@papanack.com | |||||
| Fax: 1 - (613) 673 - 5870 | |||||
| Phone: 1 - (613) 673 - 7275 | |||||