Membership Dues Name *DOB *PAL # *PAL Expiry *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *PhoneEmail Address *Confirm Email Address *CSSA Insurance *Paid By AjaxRGCSelf Paid or by Another ClubCSSA Insurance InformationCSSA #CSSA ExpiryEmergency ContactsEmergency Contact 1 – NameEmergency Contact 1 – PhoneEmergency Contact 2 – NameEmergency Contact 2 – PhoneMembership Type *Membership TypeSingle ARGC Membership (Plus CSSA Membership)Single ARGC Membership (No CSSA Membership)Family ARGC Membership (Plus Family CSSA Membership)Family ARGC Membership (No Family CSSA Membership)SpouseSpouseDOBSpouse PAL #PAL ExpiryDependentsDependent must be under the Age of 21, living at home and in School.Dependent 1 – NameDependent 1 – DOBDependent 1 – PALDependent 1 – PAL ExpiryDependent 2 – NameDependent 2 – DOBDependent 2 – PALDependent 2 – PAL ExpiryDependent 3 – NameDependent 3 – DOBDependent 3 – PALDependent 3 – PAL ExpiryPlease ensure you have selected the correct Membership Type above. If you are unsure, please ask a Board Member for direction.Payment Method *Credit CardCheque – Please mail to 1575 Ravenscroft Rd., Ajax, ON L1T 0K4e-Transfer – [email protected]Cash – At the clubARGC Membership Fee$CSSA Membership Cost$CSSA Membership Cost$Stripe Fees$Stripe Fees$Stripe Fees$Stripe Fees$Total Payable$Credit / Debit Card *Consent *I confirm that the information provided is accurate, and I authorize The Ajax Rod and Gun Club to use it for membership renewal and related communications. If I have provided payment details, I authorize The Ajax Rod and Gun Club to process my renewal payment. SubmitSave your progress
