alzfdn.ca - Membership Application

* Membership:

Member

Associate Member

* Name of Organization:

* Address:

* City:

* Province & Territories:

* Postal Code:

* Day Telephone:
(use xxx-xxx-xxxx format)

* Fax Number:
(use xxx-xxx-xxxx format)

* Website Address:

* Executive Director:

* Contact Person
(for communication from AFCC):

* Email Address:

Other Key Personnel:

	Name	Title
1.
2.
3.

* Type of Organization/Federal or Provincial:

Nonprofit Organization

For-profit Organization/Company

Federal Tax Registration Number:

* Organization Activities:

Geographic Area Served:

Number of Employees:

Number of Volunteers:

Annual Budget:

Percentage of Revenues Spent on:

	Management
	Fundraising
	Programs and Services

0/100 points

* Select Advisory Board (For Member Organizations Only):

Public Relations	Development
Advocacy	Social Services

* What are the immediate needs facing your organization?

* What are the long term needs facing your organization?

* What additional programs/services would you like to offer in the future?

For information about annual dues, please contact AFCC at

To apply for membership, please send AFCC a completed application and a copy of your latest CRA Registered Charity Information Return or the latest copy of your annual audited financial statement as well as newsletter and brochures about your organization. Click "submit" at the end of the form or print out this form and submit the completed application via fax or regular mail.

AFCC
95 Mural Street, Suite 600
Richmond Hill. Ontario L4B 3G2
Email: info@alzfdn.ca
Phone: toll-free: (877) 321-2594 or Richmond Hill (905) 882-3141
Fax: (905) 882-3132

* Indicates Response Required

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