India Canada Association
National Capital Region Ottawa ON Canada
| Membership Type |
| Lifetime ($200) Family ($20) Single ($10) Student ($10) Senior ($10) |
Applicant Information
Title Mr. Mrs. Ms. Dr. Rev.
Name: _______________________________________________________________
(Last)
(First) (Middle
Initial)
Complete Mailing Address:
(Street) _______________________________________________________________
(City)
(Province) ________(Postal Code) _________________
Telephone Numbers: Work: ___________________ Home:_____________________
E-Mail Address: ________________________________________________________
Spousal Information (Applicable
to Family or Lifetime Membership)
Name: _____________________________________________________
Dependent(s) Information (Applicable to Family or Lifetime Membership)
Name: ___________________________
Relationship:________________
Name: ___________________________
Relationship:________________
Name: ___________________________ Relationship:________________
Signature: _________________________ Date:_____________________
Please complete this form and mail it with your subscription amount to:
I.C.A, 4 Westwinds Place, Nepean,
ON, K2G 6G5 Canada
PLEASE MAKE YOUR CHEQUE OR MONEY ORDER PAYABLE TO I.C.A.