Black Rock
and Sandringham Conservation Association Inc.
|
A0021210W |
4a Fairleigh Avenue, |
Tel (03)
9598 6646 |
|
The
Membership Secretary, Black Rock and Sandringham
Conservation Society Inc: I apply for new or renewed membership
of BRASCA Inc. for 1st April 2001 - 31st March, in the class indicated below.
I agree
to be bound by the Rules of the Association for the time being in force. |
|
TICK AS TO WHETHER JOINING OR RENEWING |
Non-member
joining BRASCA Inc. |
Member
renewing membership |
|
Tick one only
please |
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|
MEMBERSHIP CLASS |
Family Membership |
Individual Membership |
Student/ Concession |
|
Donation to BRASCA Inc. |
TOTAL |
|
SUBSCRIPTION |
$15.00 |
$10.00 |
$5.00 |
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|
AMOUNT PAID |
$.............. |
$................. |
$............ |
. |
$................ |
$............. |
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. |
# # Dr/Mr/Mrs/Ms/Miss
# # (# Please circle appropriate titles) |
Given Name(s) |
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Surname(s) |
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Address |
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Postcode |
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Telephone No. Home Telephone No. Work |
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Fax No. |
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E-mail address |
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Receipts not sent unless
requested. |
Signature of Applicant
.............................................................................
Date ..................................20......