Last Name |
................................................................................. |
| First Name |
................................................................................. |
| Address |
................................................................................. |
| |
................................................................................. |
| City |
................................................. |
Province ........... |
| Postal Code |
................................................................................. |
| Phone (H) |
................................................................................. |
| Phone (W) |
................................................................................. |
| eMail |
................................................................................. |
| Birth Date |
................................................................................. |
| Occupation |
................................................................................. |
| |
 Male Female |
|
|
1
year membership for $129.00 (+ GST = $138.03)
3
month trial membership for $69.00 (+ GST = $73.83)
|
| My cheque of
$........................ for membership is included. |
| The membership fee of
$....................... is to be billed to my credit card. |
| Number...........................................................................................
|
| Expiry Date ........... /
........... |
Visa MasterCard American Express
Cheque (Payable to
The Single Gourmet) |
| |
|
| Signature |
................................................................................. |
| Date |
.................................................................................
|