SRA Membership Application Form

Name: __________________________________ Telephone: (____)_________

Address: ___________________________________

Province: ______________ Postal Code: __________

E-Mail Address: ________________________________

Former Department, Agency, or Company: ___________________________

Retirement Date (mm/yyyy): _____/________

Membership Amount Enclosed ($10 per year, up to 5 years): $_____________

Place a X mark in the appropriate box:

New Membership

Renewing Membership

Change of Address

Contribution to Legal Fund   $ __________

Total Enclosed : $___________________

___________________ __________________________

(date) (signature)

Please make your cheque payable to SRA Inc, send form and cheque in mail to:

Saskatchewan Retirees Association

Walter Scott Building

3085 Albert St.

Regina, SK. S4S 0B1