ACT Manitoba Group Membership Form
Group Membership:
Dues are $150 per year
(Sept 1 to Aug 31)

Group Registration: Please provide two contact names and details, preferably someone on your group executive.

Privacy Policy: ACT will only use your E-mail address for ACT specific notices. ACT will keep your E-mail address confidential and will not disclose it to anyone outside the ACT Board

Please print a copy of this form after you have completed it and mail it with your registration fee to:

Karen Martin
1532 Patricia Avenue
Brandon MB R7A 7K7
Ph: (204) 573-0334

Date: (Mo/Day/Yr)          
Group:
Name1:
Address:
City:   Postal Code:
Phone: Home: 204- -      Work: 204- -
Fax:    204- -
E-Mail:
  Group Registrations: Please provide second contact
Name2:
Address:
City:   Postal Code:
Phone: Home: 204- -      Work: -
Fax:    204- -
E-Mail:
  Please provide a link to our Group Website:
Website:
Payment: A Cheque for $ is enclosed with this Registration Form.

Submit form by E-mail to : ACT Secretary
Instructions for E-mailing Registration Form

Note: Your ACT Membership will commence on the date of receipt of your cheque by ACT.

Membership fees are due on Sept 1 each year