2420 Haywood Ave. West Vancouver, B.C. Canada V7V 1Y1; Phone: (604) 505-3170
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Annual Membership Fees

Individual: Organizational:
Student $5 Cultural $250
Regular $25 Corporate $500
Benefactor $1000

Full Name: ____________________ Home phone: ____________________
Home address: ____________________ Work phone: ____________________
City, Province: ____________________ Cell phone: ____________________
Postal Code: ____________________ Fax number: ____________________
Occupation: ____________________ E-Mail: ____________________

For the period of: July 1st. 20____ to June 30th. 20____
Membership fee $_______________________
(optional) Donation $_______________________
Total $_______________________
Cash___ or Cheque___ enclosed (payable to: FACE Humanitarian Society) or
Please bill me:
 		Visa # : _____________________
Expiry Date: _________________
Signature: ____________________

Please print this form and mail it with your cheque to the address above.
If you have a special interest in a particular aspect of our work, please tell us.
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Or send e-mail to: damon@youthagainstlandmines.org