MEMBERSHIP REGISTRATION FORM

Name: (Last)______________ (First)______________________________ (Chinese)___________________

Address: _______________________________________________________ (Postal Code)_______________

Tel(Res): ( ) (Bus):( )

Fax: ( ) E-mail:

Year arrived in Canada: Occupation/Trade:

I would like to become a (tick where applicable)

Regular Member: annual membership fee $20 Life Member: membership fee $200

and enclosed a cheque of CAD$__________ payable to The Hong Kong Polytechnic University (Western Canada) Association.

Introduced by: (Membership No.: )

Connection with The Hong Kong Polytechnic University (including the former Hong Kong Polytechnic and Hong Kong Technical College)

Periods of Studies	Periods of Employment	Department	Course(s) studied (for past students only)
From to	From to
From to	From to
From to	From to
From to	From to

*I agree/do not agree (delete whichever inapplicable) to add my name and phone numbers onto the Members Directory of the Association

Signature: Date:

(for office use only)

Membership No.: Expiration:

Please duplicate when necessary