The Canadian Shiatsu Society of BC

Canadian Shiatsu Society of British Columbia
C.S.S.B.C. /カナダBC州指圧協会
E-mail: info@shiatsupractor.org Web: www.shiatsupractor.org

Membership Application Form
Effective July 1st, 2015 to June 30th, 2016

Membership Status: (Please check "□", the categories which apply to you)

Professional Members	□ Shiatsupractor / SPR (full year)	$100.00
	□ Shiatsupractor / SPR (midyear; @$10 × month) Under special circumstances only	$ .
	□ Shiatsu Therapist / Supporting Member (full year)	$100.00
	□ Shiatsu Therapist / Supporting Member (midyear; @$10×month) Under special circumstances only	$ .
School Members	□ Authorized Institute	$100.00
Others	□ Application Fee (New application only)	$ 25.00
	□ Late Renewal Fee	$ 15.00
	□ Donation	$ .
	T o t a l	$ .

Certificate: (Please check one of the boxes)

□ I need the certificate to be mailed

□ I do not need the certificate to be mailed (membership number will be emailed)

Member Information: All members please fill out completely.
(Please check □, if you do not want your information to be on the CSSBC directory on our website.)

□ Name:	□ Home phone #:
□ Home address:	□ Home fax #:
□ Office name:	□ Office phone #:
□ Office address:	□ Office fax #:
□ E-mail & Website address:

Purpose statement
(a) To establish and maintain a non-profit organization of the Shiatsu practitioner. (b) To promote understanding of true Shiatsu therapy which originated with Tokujiro Namikoshi Sensei in Japan for Canadian society. (c) To promote elevation of the status as the Professional Shiatsu practitioners. (d) To assist in the improvement of the Shiatsu technique as Shiatsu Practitioners.

I fully understand the definition of Shiatsu and agree to the purpose of the Canadian Shiatsu Society of BC.

Name

Signature

Date

Please make a cheque payable to "Canadian Shiatsu Society of BC"
Mailing address: #1079-88 West Pender St. Vancouver,BC V6B 6N9