Member(s) Name(s):

Minor Children's Names & Birth Dates:

Address:

City:

Prov:

Postal Code:

Telephone:

Fax:

E-mail: (Home or Work)

Submission of the above information will be kept strictly confidential in CQHA's database, unless you specifically request otherwise as follows:

I also wish to receive communications and information direct from corporate sponsors or partners of CQHA ____ (check)

I also wish to receive communications and information direct from Equine-Hippique
Canada ____ (check)

I also wish to receive communications and information direct from corporate sponsors or partners of Equine-Hippique Canada ____ (check)

Membership Fees paid for calendar year 200__ (please check one of the following):

________"single" membership (one adult, or one adult single parent with 1 minor child 18 years & under, as of January 1 each year) = 1 vote in CQHA & Equine-Hippique Canada - Fee payable = $9.00/CQHA + $1.00/Equine-Hippique Canada = $10.00/year

________"family" membership (two adults, and all minor children 18 years & under as of January 1, each year) = 2 votes in CQHA & Equine-Hippique Canada Fee payable = $13.00/CQHA + $2.00/Equine-Hippique Canada = $15.00/year

Please make cheque payable to: CQHA and mail with this form to:
CQHA, c/o Box 1122, Carberry, MB R0K 0H0