SOUTH CHANNEL ASSOCIATION

Membership / Renewal Application Form

Jan. 1, 2005 to Dec. 31, 2005

Name New Member_____ Renewal _____

Home Address ___________________________________ City Prov/State

Postal Code / Zip Code ____________________________ Cottage Phone: Home Phone

Cottage Location ___________________________ E Mail Address __________________________________________________

List the information you would like included in the South Channel Directory :

South Channel Association Member	Cottage Address/phone	Adult Cottagers	Home Address/Phone	Children/ Ages	Fire Pump	Other Information
			.

INVOICE

Membership Fee ($63.00) Enclosed $_________________

Additional Voluntary Contribution $_________________

Total $ _________________

(Please make cheque payable to South Channel Association)

Please Mail Form by January 31, 2005 to : Ed Pintwala, Treasurer,

South Channel Association

20 Port Royal Crescent

St.Catharines Ont.

L2N 7K1