Membership Form

Name: _____________________________________________________________________

Address: ___________________________________________________________________

Postal Code: ________________________________________________________________

Telephone: ( Residence) _______________________________________________________

Telephone: (Business)_________________________________________________________

E-mail Address: ______________________________________________________________

Individual Membership: $ 15.00 Corporate $50.00 Donation: $________________
Please invoice me for my membership and I will forward my payment.
Enclosed is: Cheque # ___________ Money Order:

REGISTERED CHARITY # 89003 7997 RR0001
Mail To: EQA Education for Quality Accessibility
51 King St. East, Suite 107
P.O. Box 883
Brockville ON
K6V 5W1