MEMBERSHIP FORM
RIGHT TO DIE SOCIETY OF CANADA

Name(s)

Address _______________________________________________________

______________________________________________________________

______________________________________________________________

Telephone ______ - ______ - _________

Fax             ______ - ______ - _________

E-mail _______________________________________________________________

I enclose a cheque or money order, payable to Right to Die Society of Canada, for

__ $30 (Regular-rate annual membership, single)

__ $40 (Regular-rate annual membership, couple or family)

__ $_____ (Special-circumstances reduced rate -- please add a brief note below:)

___________________________________________________________

___________________________________________________________

__ $_____ (Regular rate plus a gift, to help fund reduced-rate memberships)

(   )   I want to be in contact with other members in my town or city or region

Mail to:
Right to Die Society of Canada
145 Macdonell Ave.
Toronto, Ontario
Canada
M6R 2A4