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The Blue Rose Gallery©
Membership Application
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Name:________________________________________ Adult /
Minor ________________
address:__________________________________________________________________
___________________________________________________email list Y/N____
Voice#______________Fax#______________ Data#_____________ Email#__________
Signature:_______________________________ Date: ___________________________
Optional Gift info. to be completed only in the desired
event of forwarding a membership as your gift to the undersigned
Name:_________________________________________ Adult / Minor _______________
address:__________________________________________________________________
___________________________________________________email list Y/N____
Voice#______________Fax#______________ Data#_____________ Email#__________
Your Area of Special Interest________________________________
Membership Fees:
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open member..________ $70.00
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initiation..........________$100.00
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other...... (gift) ________$100.00+$70.00=$170.00
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$ ________ .00 Enter Total Sum Here
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(chairperson to enter NIL and inital here for honorary membership_______
)
Please "Print" this page, complete and ''Post"
with your inquiries. (The Blue Rose Gallery, Box 107, Erin Ont. Canada,
N0B 1TO ). Upon our receipt of this application, you will then be contacted
and provided with instructions and account information for you to make
the appropriate deposit of your dues. One form per membership please. Do
Not Mail Cash. Allow 4-6weeks for delivery of your clearance. All members
agree to internal confidentiality and that all activity is considered privileged
information. Note: Please comprehend that in the interest
of confidentiality and security, we screen all new comers.
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