Membership Application Form

Fill out the form below and then print it by clicking on the "Print" button on your toolbar.
Date of application:
Surname: Given Name:
Street Address:
City: Province:
Postal Code:
Home Phone: Cell Phone:

Personal stuff:

Spouse or partner's name
Which department did you work in at BCIT?
Do you or you or spouse/partner receive superannuation from your employment at BCIT?
Yes  No 
Fee $10.00 per person per year:
(Membership year - Jan 1 to Dec 31)
Amount paid: $  Cheque: Money order:
A receipt will be issued if requested below.
I do not require a receipt: Please issue a receipt:  

  Please mail completed form together with fee to:
  BCIT Retirees' Association
3700 Willingdon Avenue
Burnaby, BC
Canada V5G 3H2