*First name

 ________________________

*Last Name

 ________________________

*Mailing address

_________________________

* City

 ________________________

* Province

 ___________________

* Postal code

 ___________________

* Phone

 ____________________

*Signature

 _______________________________

Fax

 ____________________

E-mail

_________________________________

Membership:

 If paying by cheque, please make it payable to:
Dufferin-Caledon Conservative Party

 You may also pay the fee by VISA or MASTERCARD

Card Number:______________________________________

Expiry Date:_______________________________________

Signature:_________________________________________

Mail this form and cheque (if applicable) to:
Dufferin-Caledon Conservative Party
P.O. Box 436,
Orangeville, ON
L9W 5G2

•  Conditions of Membership
  Canadian citizen or permanent resident of Canada
  Active support for the founding principles of the Conservative Party of Canada
  At least 14 years of age
  Payment by applicant of required membership fee