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NAME MR/MRS/MS…………...........………………..…………………….. D.O.B. …………......................…

ADDRESS ..................................…………………………………………………………………………..….………

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OCCUPATION &/OR SPECIAL SKILLS ...........................…..…………………………………………………

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PHONE NOS: (AH) ……………........………………………     (BH) ….............……………………………

(MOBILE) …...........……….................………………….    (FAX) ………………………….............…..
 

NOMINATED BY: …………………..............................……………………………………………………….

SECONDED BY: ……………………………………………………………..............................………………

 
INTERESTS AND SKILLS (Please list) ……………………………………………………………………………

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Type of function or activity you would like to see in the Club:

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Can you help with the running of these? Yes/No

Please return this form together with your cheque for $35 made payable to Focus 35+ Club. Your membership application will be considered by the membership committee and you will be informed of the outcome.

FOCUS 35+ CLUB
P.O. BOX 515
BENTLEIGH 3204 VICTORIA, AUSTRALIA

Ph: 03 9503 4545