CORNISH ASSOCIATION OF VICTORIA INC
Application Form for Membership
Please Print and Mail with appropriate fee to the address below:
Mr Rod Phillips, Treasurer
5 Virginia St
MT WAVERLEY VIC 3149 Australia
Surname: ______________________________
Title: Please Circle one - Mr. Mrs. Ms. Dr. Prof. Miss
Given Names: ___________________________________________________
Postal Address: __________________________________________________
Postcode: __________________ Email: ______________________________
Telephone: Home: ( ) _________________ Work: ( ) _________________
Fax: ( ) _____________________ Mobile: ____________________________
Declaration: I/We accept to be bound by the Purposes, Rules and By-Laws of the Society. Further I/We request that my/our membership be affiliated with a Branch (If applicable place a tick in the appropriate box) Ballarat r Geelong r
Signature: _________________________________
Date: __ / __ / 20___
Overseas: Please the following in Australian Currency by Bank Draft (Cashiers' Check) of:
PAYABLE TO: CORNISH ASSOCIATION OF VICTORIA INC
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| Single |
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| Family |
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| Life |
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| Please indicate if you are willing to receive the C.A.V. Quarterly Newsletter by eMail (broadband is recommended): | |||||
| r | YES | r | NO | r | BOTH |
The Association operates a number of Special Interest Groups. Please indicate the group(s) in which you may wish to be involved:
| Family History | r | Computer | r | ||||
| Heritage | r | St.Just District Group | r | ||||
| Language | r | Camborne/Gwennap Group | r | ||||
| Cornish Born | r | Music | r |
| RESEARCH NAME | TOWN/CITY | COUNTY/STATE | |||
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