Membership form

Membership FORM (print and return with your payment)

c/o Hoda Nematollahi, 4870, Côte-des-Neiges, apt. 1202, Montréal, QC. H3V 1H3

Status new member renewal

Profil student teacher builder profesionnal with CD

Identification

first name: _________________________________________________

name :_____________________________________________________

Address

(No.)__________(street)______________________________________

(app.)_________(city)________________________________________

(prov.)_______________________(postal code)___________________

Phone (_______) ___________ – _____________________(ext.)_____

Email address __________________________________________________________

Authorization : I, ___________________________________________, hereby authorize
Harpissimo-Québec to use, reproduce, and/or publish photographs and/or video that may
pertain to me — including my image and/or voice from Harpissimo-Québec`s activities and concerts for promotional uses.
Signature :                                                                   Date:

Return to :

Harpissimo Québec c/o Hoda Nematollahi, 4870, Côte des Neiges, apt. E-1202, Montréal, QC H3V 1H3

JOIN PAYMENT (payable to : “Harpissimo-Québec”)

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