Membership Application Form

Name: ________________________________________________________________

Address: ______________________________________________________________

City/Province: ___________________________ Postal Code: ____________________

Email: _________________________________ Telephone: _____________________

Former Department/Agency/Company: ________________________________________

Retirement Date: ______________________ ______________________________

(Month) (Year)

Place an X in the appropriate box/boxes:

[ ] New Membership

[ ] Renewing Membership

[ ] Change of Address

[ ] Contribution to Legal Fund -- please contribute if you are able

Membership Amount Enclosed ($10 per year; 5 yr. payment recommended): $____________

Total Enclosed: $ ______________________

Signature: ___________________________ Date: _________________________

Please make your cheque payable to: SRA Inc.

Send form and cheque to:

Saskatchewan Retirees Association

Walter Scott Building, 3085 Albert St.

Regina, SK S4S 0B1

SRA001/2010