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FREDERICTON BOULDERING CO-OP

MEMBERSHIP FORM

First Member's Name

First Name*

Middle Name

Last Name*

Phone*
First Member's Date of Birth*
I certify that I am 18 years of age or older
First Member's Signature*
Second Member's Name

First Name*

Middle Name

Last Name*
Second Member's Date of Birth*
Third Member's Name

First Name*

Middle Name

Last Name*
Third Member's Date of Birth*
Fourth Member's Name

First Name*

Middle Name

Last Name*
Fourth Member's Date of Birth*
Fifth Member's Name

First Name*

Middle Name

Last Name*
Fifth Member's Date of Birth*
Sixth Member's Name

First Name*

Middle Name

Last Name*
Sixth Member's Date of Birth*
Seventh Member's Name

First Name*

Middle Name

Last Name*
Seventh Member's Date of Birth*
Eighth Member's Name

First Name*

Middle Name

Last Name*
Eighth Member's Date of Birth*
Ninth Member's Name

First Name*

Middle Name

Last Name*
Ninth Member's Date of Birth*
Tenth Member's Name

First Name*

Middle Name

Last Name*
Tenth Member's Date of Birth*
Member's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Select number of shares. Each share is valued at $100.
# of Shares*
Personal Information Policy
I hereby give consent to the FBC to collect, use and disclose the personal information herein for the purposes stated in the FBC's personal information policy. *
I agree
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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