APPLICATION FORM

Please enroll me as a member of the Mad River Institute for Political Studies.  I pledge to assist the Institute in its work to:

1. promote the "public good" through the strengthening of the public nature of government
2. have public servants recognize their inherent responsibilities to citizens
3. create more equity in politics through the expansion of democratic measures
4. have government recognize its inherent responsibility to act directly to help those citizens who need assistance
5. have public servants adopt higher standards of conduct for themselves and all society
6. have public servants recognize their inherent responsibilities in the expenditure of tax dollars while still delivering needed public services
7. have public servants consider more innovative and original ideas to deal with problems
8. assist the public in better understanding the political process and their place in it, as well as the consequences of their political decisions.

This membership is good for a period of one (1) year.

Name



E-mail address



Street


Town/City

Province

Postal Code


Type of Membership:

Basic $20

Gold $100

Platinum $250

Diamond $1,000

We will send you an e-mail confirmation of membership application.  The membership will take effect upon approval and payment by cash, cheque, or money order.  (Please do not send cash in the mail.)  Make cheque or money order payable to:  Mad River Institute for Political Studies

We require your permission, as per the Personal Information Protection and Electronic Documents Act, to collect and keep personal information about you, such as what is in this form.  Please check this box if you consent to this.  Be assured that, to protect your privacy, the Mad River Institute will never voluntarily share your information with any outside individuals, organizations, business, or government.