CSA Hockey Helment Program
Online Application Form
Applicant's Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Facility's Information
Facility Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
How many helmets ($10.00+TAX each) are needed?
How many helmets with FACE SHIELDS ($24.00+TAX each) are needed?
TOTAL OF 20 HELMETS MAX PER APPLICATION
Helmets will be delivered in January.
Is this your first time applying?
*
Please Select
Yes
No
Other
If other, please specify
How did you hear about the CSA Hockey Helmet Program?
*
Are you a MEMBER of RFANS:
*
Please Select
Member
Non-Member
Would you like to become a MEMBER of RFANS:
*
Please Select
Please contact me
Do not contact me
Date
*
-
Month
-
Day
Year
Date
How would you like to pay?
*
Master Card
Visa
American Express
PayPal
Invoice
My Products
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Hockey Helmet
$
10.00
CAD
Quantity
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Item subtotal:
$
0.00
CAD
Hockey Helmet with FACE SHIELD
$
24.00
CAD
Quantity
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Item subtotal:
$
0.00
CAD
Save
Submit
Payment Methods
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please click one of the PayPal options to complete payment and
submit
the form.
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