Membership Form

Please print this form and mail to Co-op Radio:
Vancouver Co-operative Radio
110-360 Columbia St.
Vancouver, BC V6A 4J1

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) What is your favorite show? ______________________ Have you been a member before? [__] Yes or [__] No

FORM OF PAYMENT $________/month Monthly Sustainer ($10, $15, or $20/month) $50 Regular Member $25 Fixed Income $65 Premium Member $75 Family/Partner $102.7 Omnidirectional $125 Organization $500 Lifetime $________ Donation     $________ Total HOW WOULD YOU LIKE TO PAY? VISA/MC       Cheque/Money Order        Cash For Credit Card payments only: (Visa or Mastercard) Name on Card _____________________________________ Number___________________________________________ Card Expiry Date ___________________ (Month/Year) TAX RECEIPT INFORMATION Do you need a tax reciept? Yes [_] No [_] If yes, please make your cheque payable to CRES. If no, please make your cheque payable to Co-op Radio. Please note: All tax receipts are sent in January each year.