Myasthenia Gravis Manitoba Inc.

Membership Application

Please complete the form below and return it with your annual membership fee ($10 per family or $5 per person). Membership fees are for the year starting October 1^st and ending September 30th. Paid members are entitled to vote at the annual meeting of the corporation or at any special meeting of the corporation. Members receive a copy of the newsletter published by the corporation. The mailing address for Membership is:

Myasthenia Gravis Membership

c/o Maureen Silk

614 Munroe Avenue

Winnipeg, Manitoba

R2K 1H8

Membership Application

(Period October 1^st, 2005 to September 30^th 2006)

LAST NAME _______________________ FIRST NAME ____________________

STREET _____________________________________________________________

CITY _______________________________ PROVINCE ______________________

HOME PHONE ______________________ POSTAL CODE __________________

MEMBER WITH MG: __________________________________________________

EMAIL ADDRESS _____________________________________________________

FAMILY MEMBERS: ___________________________________________________

___________________________________________________

___________________________________________________

Membership fee enclosed: ___________________

Donation enclosed: ________________________

Membership Application

LAST NAME ___ FIRST NAME

STREET _____________________________________________________________

CITY _________ PROVINCE