2011 Membership Annual renewal Form
Gabriola Historical & Museum Society
PO Box 213
Gabriola, BC Canada
V0R 1X0
| Family $20.00r | Couple $15.00r | Indivdual $12.00r | Senior $10.00r | Student $10.00r | |||||||
| Bronze $50.00r | Silver $75.00r | Gold $150.00r | Donationr | Amount of donation $____.__ |
| Platinum(25 years) $2,500.00r | Family (25 Years) $1,000.00r | Indivdual $500.00r |
| Corporate Sponsor per year $50.00r | Business Sponsor per year $250.00r |
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address Mr. r Miss r Ms r Mrs r First Name: ________________________________________ Last Name: ________________________________________ Company: _________________________________________ Address: __________________________________________ __________________________________________________ City : ___________________________________________ Postal Code/ Zip :_____________ Country :____________ Phone Number ( _ _ _ )- ( _ _ _ )- ( _ _ _ _ ) Email : ___________________________________________ |
Gift address Mr. r Miss r Ms r Mrs r First Name: ________________________________________ Last Name: ________________________________________ Company: _________________________________________ Address: __________________________________________ __________________________________________________ City : ___________________________________________ Postal Code/ Zip :_____________ Country :____________ Phone Number ( _ _ _ )- ( _ _ _ )- ( _ _ _ _ ) Email : ___________________________________________ |