Your Legal Full Name:
Chapter/University:
E-mail Address:
Confirm E-mail:
Cell Phone:
Social Insurance Number:
Confirm SIN:

"Permanent Address

(preferably parent's)
Street:
City:
Province:
Postal Code:
Phone:

School Address

{% trans "If same as above, please place an x in each of the fields below.
Street:

City:
Province:
Postal Code:
Phone:

Please Note: It is your responsibility to notify the Foundation of any address changes.

Administrative
Cheques to be mailed to:
Comments/Notes/Other Information


PLEASE NOTE: T4As will be mailed out each FEBRUARY
for all funds you received in the previous calendar year.

T4As will only be mailed to your permanent address.

I verify that the information provided in this form is true to the best of my knowledge.

If you are completing this form on behalf of someone else, please indicate your name, e-mail,
and phone number in the "Other Information" box above.