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Cluster # (i.e. SK-200-02) _____________________
Province:________________City:______________________________
Chapter
Name:_____________________________________________
Queen's
Name:_____________________________________________
Queen's
Address:___________________________________________
__________________________________________________________
Queen's
Phone #:___________________________________________
Queen's
Email:______________________________________________
Number
of new members to add________ @ $8.00 ea = __________
Total amount enclosed: #____________________
Cheque/Money
order payable to "L.Millard"
Mail to:
L. Millard
935 Bartholomew Ct;
Kelowna BC V1W 4N2
Please be sure to write your insurance cluster number on all
correspondence (i.e.
105-B)
LIST NAMES TO BE ADDED TO POLICY
Please
print clearly and use legal names (i.e. Patricia Smith not Pat Smith) | 
