Funeral

Become a member of Flowercity Community Services

Flowercity Community Services — Funeral Services Membership Form

Please fill out all required fields to complete your membership application.

Section 1 — Applicant Information

Applicant First Name *

Applicant Last Name *

Date of Birth (DD/MM/YYYY) *

Gender *

Address *

City *

Postal Code *

Phone Number *

Email *

Next of Kin Name

Next of Kin Phone Number

Emergency Contact Name

Emergency Contact Phone

Section 2 — Spouse Information

Spouse First Name

Spouse Last Name

Address

City

Postal Code

D.O.B / Age

Phone

Next of Kin

Next of Kin Tel #

Section 3 — Membership Details

One-Time Principal Membership Fee: $100

Additional Family Members: $25 each

I understand that husband and wife count as one member.

Additional Family Members Fee

Section 4 — Pre-Authorized Payment Agreement

Authorized Amount

Bank Account Number

Institution Number

Branch Code

Withdrawal Day

Bank Name & Address

Donation on behalf of:

Individual Business

I may revoke authorization with 30-day notice. I have recourse rights in case of unauthorized debit. I agree to pay funeral share costs as divided among principal members. Deduction not to exceed $20 maximum. I will inform the society of any changes in my information.

Section 5 — Signature

Applicant Signature *

Date *