Reflexology Association of Canada #201-17930 ~ 105 Avenue Edmonton, Alberta T5S 2H5 780-484-2097   toll free: 1-888-889-5394   fax: 780-444-6882 administration@reflexologycanada.ca MEMBERSHIP RENEWAL FORM FOR 2001 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: ___Cheque ___Cash ___Money Order ___Visa ___MasterCard Amount: _____ Card Number: ________________ Expires: ____________ Signature: ___________________________ Payable in Canadian Funds, please. ------------------------------------------------------------------------ Office Use Only: _______Entered by MA _______Entered by BK _______Receipt # _______Receipt Date