*First and Last Name:_________________________________________________________

*Address 1:_________________________________________________________________

Address 2:_________________________________________________________________

*City or Town:_____________________________ *Province:__________________________

*Postal Code:___________________ *Email:_______________________________________

Home Phone:__________________________ Business Phone:___________________________

|_| $10.00 party membership only (required to vote for Enza – expires in 1 year)
|_| $25.00 party membership plus donation for Enza’s campaign

|_| $50.00 party membership plus donation for Enza’s campaign
|_| $100.00 party membership plus donation for Enza’s campaign
|_| Other: $_______.00

THE SMALL PRINT (required under the rules of the Canadian Alliance):
I acknowledge that I am a Canadian citizen or landed immigrant, ordinarily resident in Canada, 16 years of age or older. I support the principles of the Canadian Alliance and agree to abide by the Alliance constitution.

MEMBERSHIP EXPIRES AFTER ONE YEAR OR UPON REQUEST.
|_| I enclose my cheque for my party membership/donation as noted above.
(Please make your cheque payable to “ENZA SUPERMODEL CAMPAIGN” and deliver or mail it to the address below.)

|_| I wish to pay the above amount by VISA.
|_| I wish to pay the above amount by MASTERCARD. 

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