Tel: (204) 925-5668 200 Main Street, e-mail:info@mbbroomball.com
Fax: (204) 925-5703 Winnipeg, MB R3C 4M2 Website:www.mbbroomball.com
Toll Free in Manitoba: 1-866-792-7666
TEAM AFFILIATION – Year_________
Annual affiliation due on or before December 31st
Annual affiliation fee $100
Team Name: _________________________________________________________
Category: Check one
Men’s Contact: ____________ Co-ed A: _____________
Men’s Non-contact: ____________ Co-ed B: _____________
Women’s Contact: ____________ Co-ed C: _____________
Women’s Non-contact: ____________ Juvenile Boys: _____________
Juvenile Girls: ____________
Team Contacts All information will be forwarded through these contacts. Please include e-mail where applicable as that will be the preferred medium for correspondence.
Name: ___________________________________ Address: _________________________
City/Town: _______________________________ Postal Code: ______________________
Telephone: _______________________________ E-mail: __________________________________________
Fax: ____________________________________
Name: ___________________________________ Address: _________________________
City/Town: _______________________________ Postal Code: ______________________
Telephone: _______________________________ E-mail: _____________________________________
Fax: ____________________________________
Please make cheques payable to Manitoba Broomball
