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Membership Renewal Form for 2001

If you would prefer to print the renewal form from your word processor, and mail or fax it in, click here for a plain text version.

We strongly suggest you provide for yourself a back-up of your material because of possible transmission errors in sending along this online version. You might consider preparing your longer answers in a word processor and then cut-and-pasting them into this form.


Date:

Membership #

Foot Certificate #

First Name:

Last Name:

Street: City:

Province:

Country

Postal Code:

Telephone (home):

Telephone (work):

Fax:   Email:

Support Information

Are you a member of one of the chapters listed below?
Yes No

British Columbia Chapter | Ottawa Valley Chapter

Simcoe Chapter ON | Peace Chapter ~ Beaverlodge AB

Manitoba Chapter | Edmonton Chapter AB

Foothill Chapter ~ Calgary AB | Saskatchewan Chapter

Niagara Chapter | Golden Triangle Chapter ON

London Chapter ON | Nova Scotia Chapter

Other:


Referral List Information

I wish to be listed in the referral book? Yes No

NOTE ~ The following information is that which you want the public to have. You will only be placed on the lists you select. Referral listing is available only to RAC certified Reflexologists.

Nearest Intersection (Ex: King St and John St):
and

City:

Province:

Telephone (home):

Telephone (work):

Fax:   Email:

Will you do housecalls? Yes/Negotiable No



Method of Payment:

Amount:

Card Number:

Expires:

Payable in Canadian Funds, please.

Remember ~ in case of transmission error when sending along this completed form, cut-and-paste your longer answers to your word processor.



Any materials for mailing
(cheques, money orders, etc.) go to:

Reflexology Association of Canada
#201-17930 ~ 105 Avenue
Edmonton, Alberta T5S 2H5

tel: 780-484-2097   toll free: 1-888-889-5394
fax: 780-444-6882

PLEASE NOTE: Your form will not be processed until payment is received.




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