To: Western Canada Concept 
Box 101, 255 Menzies Street
Victoria, B.C. 
Western Canada V8V 2G6 
Phone: 250-385-1022, Fax: 250-479-3294

I, the undersigned, realizing Western Canada should be an independent nation, 
chosen by referendum in each province, hereby pledge to work with the movement
 under the leadership of Douglas Christie to achieve this goal. 

I will faithfully advance the interests of my new country and give to others an 
example of dedication and service by my work. 

I seek membership in the Western Canada Concept. 

Signature:___________________________________________ 


PLEASE PRINT THE FOLLOWING INFORMATION: 

Mr.( ) Mrs.( ) Miss.( ) Ms.( )

First Name:_________________________________________ 

Last Name:_____________________________________________________________________________

Address: _______________________________________________________________________________ 

______________________________________________________________________________________

Email address:___________________________________________________________________________

Telephone:__________________________ 


I offer to do the following: (please check all applicable) 

Local Meetings ( ) Canvassing ( ) Local Organizing ( ) Local Telephone Committee ( ) Fund Raising ( )

Reporter for Newsletter ( ) Other ( ) (specify) 

_______________________________________________________________________________ 

_______________________________________________________________________________ 

Membership fee of $15.00 enclosed( ) 
Donation of $__________enclosed( )