Head Office

P.O. Box 84030 RPO

5353 Lakeshore Rd.
Burlington, Ontario
L7L 6S2

Member's Renewal Form and Statistics

Please Print and Complete Form
First Name:
Surname:
Address:
Address:
City/Town:
Prov./State:
Postal/Zip Code:
Country:
Res. Tel.#:
Bus. Tel. and Ext#:
Fax #:
Email:
Website:
Member #:
Current Membership
Expiry Date:
To be added to the
website under Find a
Reflexologist:

YES

OR

NO

Please make payable to the Treasurer with your $75.00 payment (Cheque or PayPal).

ADD TO PAYMENT IF ANY OF THESE APPLY:

NSF ($45.00) Past Due Date Fee ($25.00).
Treasurers Office Use Only
Date Received

Printed: June 25, 2015

Amt. Paid

How Paid

Date Received

Receipt #

Date Sent

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