Formulaire d'ajout aux listes de l'Association Polio Québec's lists registration form

Si vous éprouvez de la difficulté à remplir le formulaire, n'hésitez pas à nous contacter.
If you have any difficulty filling the form, don't hesitate to contact us.

association@polioquebec.org
514 489-1143
1-877-765-4672 (1-877-POLIO-QC)

Les questions avec une étoile rouge sont obligatoires
The questions marked with a red star are mandatory

    Information personnelle / Personal information

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    Communication

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    Cotisation et/ou don / Membership and/or donation

    **CE DOCUMENT N'EST PAS UNE CONTRIBUTION** Assurez-vous de nous faire parvenir le montant de votre cotisation (25$ pour un an) et/ou votre don par chèque ou par carte de crédit grâce au paiement sécurisé de PayPal en suivant ce lien : http://bit.ly/2rDqJ7K **THIS FORM IS NOT A CONTRIBUTION** Make sure to send us the amount of your contribution ($25 per year) and/or your donation by cheque or credit card with PayPal secured payment by following this link : http://bit.ly/2rDqJ7K
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