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The Bar

123 Main Street,


Sherbrooke, Qc
G1X 0T2
CANADA

Membership registration

First name:………………………. Last name:……………………………..

Address:………………………………………………………………………
(street) (city) (country)

Postal code:………………………………………………………………….

Profession: ………………………………………………………………….

Nationality:…………………………………………………………………..

Phone: ………………………………… Cell: ……………………………

Birthdate: ………………… …………. ……………


(Year) (month) (day)

Are you currently a member: ………. yes ………….. No

New member $50.00 ……………. member $30.00 ……….

Signature: ………………………………………………………………………..

Date:……………/………………../……………….

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