Membership & Donations


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First Name:
Last Name:
Organization:
Address:
City:
Province:
Postal Code:
Telephone:
Fax:
E-mail:
Riding:
Click here to look up your riding


Our basic annual membership fee


Individuals - $25
Family - $45
Health Professionals - $100
Retailers and Organizations - $200
Manufacturers and Distributors - $500

Total $:

Please invoice me directly:
or charge my credit card:

Card #:

Expiry:

Enter the words below:
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