Memberships

First Name

Middle Name

Last Name

Address: Street #, Street Name, Apt/Unit

City, Province

Postal Code

Phone Number

Home Number (Telephone)

Email Address

Next Of Kin

Spouse

How Many Children?

Child 1 Name

Child 1 Date of Birth

Child 2 Name

Child 2 Date of Birth

Child 3 Name

Child 3 Date of Birth

Child 4 Name

Child 4 Date of Birth

Child 5 Name

Child 5 Date of Birth

Child 6 Name

Child 6 Date of Birth

Membership Fees Per Year Membership Fees Per Year$240.00 Per Family$180.00 Single$60 Unemployed - Single$120.00 Unemployed - Family

Method Of Payment Method Of Payment Cash Void Cheque E-Transfer: Email Address: SCCA.London.On@gmail.com

Message For SCCA London (Optional)

Acknowledgment Acknowledgment By Sending This Form, I/We hereby undersign to be a member of the Sudanese Canadian Community Association of London and Area and adhere to its rules and regulations as spelled out in its constitution, bylaws, code of conduct, and any other rule(s) issued by the board of Directors. I/We know that if one becomes delinquent his/her membership may be suspended or revoked. Checking This Will Be YOUR and (if applicable) YOUR SPOUSES Signature.