New       Renewal       Correction        Order         Donation

Membership Type:
Household: $20 (include both names)
Life Membership:$250
Organizational Membership: $60
Corporate Membership:$200

Donation: (Thank-you)
Tax receipts are issued for donations of $10 or more and membership fees.

Other (specify): 

Name(s): 

Address: 

City:   Province:  Alberta British Columbia Manitoba Manitoba New Brunswick Newfoundland/Labrador Northwest Territories Nunivit Ontario Prince Edward Island Quebec Saskatewan Yukon   Postal Code: 

Phone: ()-  E-mail: 
E-mail will used for the purpose of membership renewal notices only.

Age:     Under 65     65-85      Over 85

Privacy:
Check here if you do not want to receive information from Johnson Inc. regarding insurance.
Check here if you do not want your name published in ACA News as a donor.
ACA does not sell or rent our membership list under any circumstances.

Method of Payment:
  Cheque*     Cash (do not send cash in the mail)    AMEX     Mastercard    Visa
*Make cheques payable to the Alberta Council on Aging

Card Number: ---    Expiration Date:/

Signature: