25- And 50-Year Membership Certificate Request Form
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125- and 50-Year Membership
Certificate Request Form
Please allow two weeks upon receipt at provincial office for processing
Recipient’s full name
Years of membership
iMIS number
(please print clearly)
(including girl years)
1
2
3
4
5
6
Area award adviser’s name & e-mail/phone #
Date certificate required
(specific date, not ASAP)
Month of presentation
(will appear on certificate)
Delivery method
(check one)
Name, address & e-mail/phone #
Mail via Xpresspost to
Courier to
(note that cost will be charged back to your area)
Name & e-mail/phone
Pick up at provincial office by
rd
(at 3
floor volunteer pick-up desk)
Additional instructions
Area award adviser’s signature
(if the position is vacant, Area Commissioner or
her deputy must sign)
Area
Date
Send completed form to committee assistant at provincial office via e-mail
() or fax (604-714-6645)
FOR OFFICE USE ONLY
WO #
Date received
Entered into database
Date mailed
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Parent category: Business