ACT Manitoba Group Membership Form

Group Membership:
Dues are $100 per year
(Sept 1 to Aug 31)

Group Registration: Please provide two contact names and details, preferably someone on your group executive.

Privacy Policy: ACT will only use your E-mail address for ACT specific notices. ACT will keep your E-mail address confidential and will not disclose it to anyone outside the ACT Board

Please print a copy of this form after you have completed it and mail it with your registration fee to:

Donna Cuddy
Box 105
Holland, R0G 0X0
Ph: 526-2379(H)
Ph: 723-2781(W)
Fax: 723-2867

 Date: (Mo/Day/Yr)          
Group:
Name1:
Address:
City:   Postal Code:
Phone: Home: 204- -      Work: -
Fax:    204- -
E-Mail:
  Group Registrations: Please provide second contact
Name2:
Address:
City:   Postal Code:
Phone: Home: 204- -      Work: -
Fax:    204- -
E-Mail:
  Please provide a link to our Group Website:
Website:
Payment: A Cheque for $ is enclosed with this Registration Form.

Submit form by E-mail to : ACT Secretary
Instructions for E-mailing Registration Form

Note: Your ACT Group Insurance and Membership will commence on the date of receipt of your cheque by ACT.

Membership fees are due on Sept 1 each year for uninterrupted coverage.