Yes, I support the work of the world federalist movement in Canada.

STEP 1
Please print or type your name, mailing address, phone and fax numbers and e-mail address, and circle the title of your preference.

Mr./Ms/Miss/Mrs./Dr./Hon./Rev./No Title

First Name ___________________________ Last Name __________________________

Organization's Name if applicable

________________________________________________________________________________

Mailing Address ___________________________________________________________________

Postal Code _______________

Telephone ( ____ )___________________ Fax ( ____ ) _________________

E-mail ______________________________________

STEP 2
Please choose the type of support you can provide. You can select an annual membership, a charitable donation or both.

An annual membership in the World Federalists of Canada. Circle the membership category appropriate to you.

Individual: $35 Household (two or more persons): $50 Contributon: $75 Limited Income: $12

A charitable donation to the World Federalist Foundation. The charitable number for the World Federalist Foundation is 12399 8957 RR0001.

STEP 3
Please return the form, indicating your method of payment.

I enclose a cheque for $ ___________ made payable to the World Federalists of Canada as my annual membership.

I enclose a cheque for $ ____________ made payable to the World Federalist Foundation as a tax creditable donation.

Charge my VISA/ MasterCard for $ ___________ as payment for my annual membership.

Card Number __________________________ Expiry Date_____________

Signature _____________________________

Charge my VISA/ MasterCard for $ ___________ as payment for my charitable donation.

Card Number __________________________ Expiry Date_____________

Signature______________________________

Total Amount Enclosed: $_______________

Note: (1) We wish to acknowledge in Mondial all supporters who contribute more than $35.00 in the year. If you do not want your name published in Mondial, please check here [_____].

(2) To build our base of support for world federalism cost effectively, we may want to trade our supporters' names once in the year with other world-minded organizations for one-time use only. If you do not want your name traded, please check here [______].

Mailing Address: World Federalists of Canada, Suite 207, 145 Spruce Street, Ottawa, Ontario K1R 6P1