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2004 Atlantic Young Liberals Caucus - Pre-Registration Form

(Please Print)

Name______________________ Telephone____________________

E-Mail Address:                                                                                            

Mailing Address___________________________________________

___________________________________________

Federal Riding____________________________________________

City/Town________________________ Postal Code_____________

D.O.B (year/mm/dd)_______________________________________

Position in Young Liberals__________________________________

PAYMENT ENCLOSED:

Delegate Registration

TOTAL:______________

* Please enclose form with cheque, payable to:

Newfoundland and Labrador Commission of Young Liberals