Canada Science and Technology Museum

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Membership Registration Form

Please indicate the category of interest and complete the personal information and gift membership information sections, as applicable.

Basic* Plus*

Individual $26.50____ $53.00____

Household $53.00____ $84.80____

Associate $42.40____

Senior $21.20____

Grandparent $42.40____

Caregiver $42.40____

*Includes GST
Please call the Membership Office to register for Group memberships.

Personal Information

New member ___ Renewing member ___
Membership card no. ________ Gift membership ___

Name ____________________________________________
Full name as it will appear on membership card

Name _____________________________________________
Full name of the second cardholder
(excluding Individual categories)

Address _______________________________

City_________________________ Province/State_______

Postal Code/Zip code___________________________

Telephone (home) ______________ (work) ______________

E-mail: _______________________________

The Membership Office will periodically send you electronic mailings with important information so you don't miss out on any of the fun or benefits of being a member!

Correspondance: English___ French___

Gift Membership Information

Purchaser's name ________________________________

Address ________________________

City ______________________ Province/State ___________

Postal code/Zip code __________________

Telephone (home) ______________ (work) ______________

Gift membership package should be mailed to:

___ Purchaser (details supplied directly above)
___ Recipient(s) (details supplied in personal information section)

Method of payment

Total $_______($CDN)

___ Cheque enclosed
(made payable to Canada Science and Technology Museum Corporation)

____ Visa ____ MasterCard

____________________ ___/___
Card number no. Expiry date

Cardholder's name ____________________________________

Signature ___________________________________________


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