COMMUNITY STREET EVANGELIST OUTREACH 402-50 Station Street Ajax, Ontario L1S 0E2 Garry W. Cuthbert - PHONE:289-660-0141 – CELL: 905-409-0452 Email:[email protected]Stephen A. Parris – Phone – 1-289-660-1951 Email:[email protected]Money Order: Name: Phone: Current address: ZIP Code: How long? Employment Information Current employer: How long? Fax: ZIP Code: Annual income: Emergency Contact Name of a relative not residing with you: Phone: ZIP Code:
Signatures I authorize the verification of the information
provided on this form as to my credit and employment. I have
received a copy of this application.
Date:
Date:
Individual membership fees: [$100.00] per member{s}
Name:
Bank Draft: [ ] Money Order: [ ] Cash: [ ]
Name:
Bank Draft: [ ] Money Order: [ ] Cash: [ ]
Name:
Bank Draft: [ ] Money Order: [ ] Cash: [ ]
COMMUNITY STREET EVANGELIST OUTREACH 402-50 Station Street Ajax,
Ontario L1S 0E2
Garry W. Cuthbert - PHONE:289-660-0141 CELL: 905-409-0452
Email:[email protected]
