If there is a blank space, the club, committee or council does not have one as yet, enter the last number that appears with your License Number at the end of the number line below. If this information is not provided, please complete and submit your business license number or name. If you are applying for a Club or District membership using the Service Canada system, make sure to complete all the sections in this section as well.
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C LU B SU PPI ES ORDER F ORM MAKE A COPY OF THIS ORDER FOR YOUR RECORDS Name Country Club Name or District (REQUIRED TO PROCESS ORDER) Street Address Phone Fax City State Zip Code Email Payment method:
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