Mahone Islands Conservation Association
Membership Form

[  ] I would like to become a member of the Mahone Islands Conservation Association.

Annual membership fee is $10 per person.  


Name        _________________________________________

Address     _________________________________________

City/town   __________________ Prov/State____________

Postal Code  ________________ Country________________

Telephone(H)_________________ Telephone(W)___________

email        ________________________________________

Organization ________________________________________


Number of members: _______  X  $10.00  = $ __________

[  ] I would like to donate an additional 
     amount toward MICA's efforts:       $ __________

                                 TOTAL   $ __________


A charitable tax receipt will be issued for all donations other than membership fees. 
MICA has obtained charitable status.

Please make cheque payable to "Mahone Islands Conservation Association". 

Please mail to: MICA, 189 Hirtle Cove Rd, Oakland, Mahone Bay, B0J 2E0 Canada