PERSONAL INFORMATION Please print clearly Name Phone Number Email Mailing Address: City Province Postal Code Canadian citizen? Yes No (CRTC Policy says that we must be 80% Canadian owned) Favourite Show? Have you been a member before? Yes or No

FORM OF PAYMENT Monthly Sustainer: $10/mo $15/mo $20/mo or $ /mo Annual Membership $60 $100 $250 $500 $1,000 $1,500 $2,000 Pay What You Want…………………..…….…........$ Organizational/Business Annual Membership…...$125 Donation ..……………………………….........………...$ Total Amount to be Paid……..………..…......…….….$ HOW WOULD YOU LIKE TO PAY? VISA/MC        Cheque/Money Order        Cash Name on Card Number Card Expiry Date (Month/Year) TAX RECEIPT ? Yes No Yes, please make your cheque payable to CRES. No, please make your cheque payable to Co-op Radio. Please note: All tax receipts are sent in January each year.