LITTLE RIVER HISTORICAL SOCIETY INC.
MEMBERSHIP APPLICATION FORM

Please PRINT this form, complete your details and send it, along with your payment, to the following address:

Little River Historical Society
c/ Post Office, Little River, VIC 3211

NAME:
STREET ADDRESS:
SUBURB:
STATE & POSTCODE:
PHONE:
E-MAIL:

MEMBERSHIP TYPE (Please Tick):

  Individual ($30.00 per year)
  Family ($50.00 per year)
  Friends of the Society - Over 65s ($10.00 per year)
  Honorary - Over 80s (no fee)

FEE ENCLOSED*: $

(*Cheques should be made payable to the Little River Historical Society)

I hereby agree to abide by the terms and conditions of the Little River Historical Society:

SIGNED:
DATE:

Privacy Note: The information provided on this form is intended for use solely by the Little River Historical Society. The information will not be used for any other purpose, nor provided to any other person or organisation, without the permission of the owner.