ACAP - The American and Canadian Association of Peru

Membership Application

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Direct Deposit to the account of "Asociación Americana y Canadiense del Perú"
SCOTIABANK (US$) # 000- 3441295 | (S/.) # 000- 7156405
Fax deposit slip to office at 441-4545

LAST NAME	FIRST NAME		M.I.
CITIZEN OF: USA CANADA OTHER	OCCUPATION (even if not presently employed)

SPOUSE'S NAME		CITIZENSHIP
DEPENDENT CHILDREN (if any) - NAME(S) AGE, CITIZENSHIP, SCHOOL ATTENDED
LIMA HOME ADDRESS	PHONE		E-MAIL
BUSINESS ADDRESS:
COMPANY NAME	POSITION		E-MAIL
ADDRESS	PHONE(S)		FAX(ES)
NEWSLETTER TO BE SENT TO: OFFICE HOME
PREVIOUS OVERSEAS POSTS:
COUNTRY - FROM - TO		EXPECTED LENGTH OF STAY IN LIMA
HOME TOWN, STATE/PROVINCE		CHURCH AFFILIATION (OPTIONAL)
BLOOD LISTING:
NAME		TYPE
NAME		TYPE
NOTE: Blood should not be donated if the prospective donor has ever had hepatitis, diabetes, malaria, Malta (Undulant) fever or venereal disease or has tested HIV Positive or is anemic.
PLEASE SELECT ACTIVITIES IN WHICH YOU ARE WILLING TO PARTICIPATE:
NEWSLETTER: Editor Co-Editor Reporter Photographer Word Processing Proof Reading Columnist Assist with Office Mailings Solicit Advertising		PICNICS: Ticket Sales Work food, Beverage booths Solicit Advertising
		WHAT OTHER ACTIVITIES ARE OF INTEREST TO YOU?
WHAT OTHER ORGANIZATIONS DO YOU BELONG TO IN LIMA?
AMERICAN CHAMBER OF COMMERCE WOMEN'S LITERARY CLUB ROOSEVELT SCHOOL PTA CANADIAN WOMENS CLUB OTHER (Especify)		WHAT ACTIVITIES CAN YOU SUGGEST FOR THE ASSOCIATION TO OFFER?
PLEASE TELL US A LITTLE ABOUT YOURSELF AND YOUR FAMILY:	YOU		YOUR SPOUSE
COLLEGE, YEAR GRADUATED
GRAD SCHOOL, SPECIALTY, YEAR
SPECIAL HONORS OR TITLES
ANY COMMENTS: