Surname: _______________________________

  First Name: _______________________________


 Bus. Tel: ________________________________

 Home Tel: ________________________________


  Web  Site______________________________________________   

Citizenship: Canadian or other: _____________________________

 Representing Publication or Electronic Media: __________________ 


Language of Medium: ________________________________

  Position of Applicant: _______________________________  

Profession: (if other) _______________________________________

 Years in Journalism: ________________________________

  Brief professional experience: ______________________________


  Sponsored by: I ____________ do certify and assure the Board that I 

have no past or  outstanding criminal convictions in Canada.


Signature of Applicant: _______________________________


 Date: ___________________________

 Please enclose two copies of the last two issues of your publication

For Internal Use Only

Accepted: □Yes No Date of Acceptance: _______________________

Signatures of the members of the Admission Committee: 1. 2. 3. Please enclose a cheque of $ 25.00 dollars for membership per annum. Please be advised that every medium has only one vote at the general elections.