Green Party of Saskatchewan
Membership Application / Donation Form

Name:____________________________________________________

Address:__________________________________________________

City / town: _______________________________________________________

Postal Code: ____________ Phone: Home:____________  Phone work:  _____________

Fax: ___________________ Provincial constituency if known   ______________________

email:_____________________________

Land description if rural resident: __________________________________

I’ve read and agree with the GPS statement of Principles.

Signature :______________________________________ Date__________________

Check all that apply:
___I’d like to join the Green Party of Saskatchewan (Provincial) Fee $10.00 / yr.
___I’d like to join the Green Party of Canada (Federal) Fee: $10.00 / yr.
___I’d like to make a donation of $ ____________

Cheques for the total amount should be made payable to the Green Party of Saskatchewan and returned along with this form to the regional office at:

Green Party of Saskatchewan, Provincial Office, 2138 McIntyre Street, Regina, Sk. S4P 2R7 (306) 352-0219

You can also make a payment using your credit card. Any credit card information provided will be only used for this purpose. Identifying card member information will be destroyed after processing.

Credit Card: VISA ____ , MASTERCARD ____

Card holder’s name as on card: ____________________________________
Card number _________________________________   Expires on _______________
Authorizing signature of cardholder:____________________________________ Date:_________________
Address of card holder: ___________________________________________________

For more information, please call the GPS Office at the above phone number. See our policy positions at www.greenpartysask.ca