YUKON SCIENCE INSTITUTE
APPLICATION FOR MEMBERSHIP 2007-2009
(October 1, 2007, to March 31, 2009)

Please return this form:
  		 Yukon Science Institute
		   P.O. Box 31137
		   Whitehorse, Yukon  Y1A 5P7


Name:________________________________________________________________

Organization (if applicable):

_____________________________________________________________________

Mailing Address:

_____________________________________________________________________


_____________________________________________________________________
(City)                                                  (Postal Code)


Telephone: Work (    )_____-_______ Home (   )_____-_______


Email: _______________________________________________


Are there activities of the Institute in which you would like to be involved?


______ Become a board member

______ Billet guest lecturers

______ Yukon Science Fair

______ Other


Membership Category:

_____ Individual $5.00

_____ Family $10.00

_____ Organization $25.00


Annual dues enclosed: ___________________

Do you require a receipt? YES_____ NO _______

Renewal _____ New Member ______