GOLD CLUB MEMBERSHIP FORM

Gold Club Membership

Name(Required)

First Last

Title(Required)

Employer (Company)(Required)

Work Phone(Required)

Mobile(Required)

Email(Required)

Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address(Required)

Same as previous

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are you a new member or returning?(Required)

New Member

Returning Member

Where did you hear about Gold Club?

What event are you looking forward to?

Payment Options(Required)

Pay in Full Online ($1600 + HST)

Pay By Cheque

Pay by Installments (We will be in contact to discuss)

Credit Card(Required)

Cardholder Name

Card Details