Membership form

Organisation (producer, presenter, ensemble, etc.)

Contents of the coloured fields will appear on our web site.

	First time
	Renewal	Invoice number (if applicable):

	Organisational member (2 votes)	$50	(annual budget under $150,000)
	Organisational member (3 votes)	$100	(annual budget over $150,000)

CNMN membership is good for one year, from January 1 to December 31.

	French
	English

This question helps us eliminate spam.

Add 2 and 3

Official English name of organisation		Acronym
Official French name of organisation (if existing)		Acronym
Contact first name
Contact last name
Contact title

Address (no, street, apartment)
City
Province
Country
Postal code
Phone
Main Email address (mandatory field)
Contact phone
Contact email address (mandatory field)
Web site

Please select the category (or categories) — if any — that best describe you. This information will be used for our web directory.

	check, money order to CNMN (Only if you “print” this document to mail to: 416, rue McGill — Montréal QC H2Y 2G1)
	VISA
	MasterCard
	American Express

Fill-in only the first 8 digits (one per box) of your card.

Cardholder name
VISA, MasterCard or American Express credit card number	- - X X X X - X X X X
Expiration date (ex.: 06/14 for June 2014)	X X / X X

Note: The merchant name on your credit card statement will be DIFFUSION i MéDIA.

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