To: Western Canada Concept
Box 101, 255 Menzies Street
Victoria, B.C.
Western Canada V8V 2G6
Phone: 250-385-1022, Fax: 250-479-3294
I, the undersigned, realizing Western Canada should be an independent nation, chosen by referendum in each province, hereby pledge to work with the movement under the leadership of Douglas Christie to achieve this goal.
I will faithfully advance the interests of my new country and give to others an example of dedication and service by my work.
I seek membership in the Western Canada Concept.
Signature:___________________________________________
PLEASE PRINT THE FOLLOWING INFORMATION:
Mr.( ) Mrs.( ) Miss.( ) Ms.( ) (please check one) First Name:_________________________________________
Last Name:_____________________________________________________________________________
Address: _______________________________________________________________________________
______________________________________________________________________________________
e-mail address:___________________________________________________________________________
Telephone:__________________________ Fax:________________________________________________
I offer to do the following: (please check all applicable)
Local Meetings ( ) Canvassing ( ) Local Organizing ( ) Local Telephone Committee ( ) Fund Raising ( )
Reporter for Newsletter ( ) Other ( ) (specify)
_______________________________________________________________________________
_______________________________________________________________________________
Membership fee of $15.00 enclosed.( )
Donation of $__________enclosed.( )