Application for Membership renewal form 3 - WYONG FAMILY HISTORY GROUP Inc

WYONG FAMILY HISTORY GROUP Inc

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APPLICATION FOR MEMBERSHIP RENEWAL

1.1.2019 - 30.6.2019

Single membership $20.00
Family membership $30.00

Personal information

* Indicates required field

Title *

Mrs Ms Miss Mr

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Postal Address (if different) *

Line 1

Line 2

City

State

Zip Code

Country

Contact phone number (s) *

Mobile phone number *

Email *

Past/Present Occupations *

In Case of Emergency Contact Name and Phone Number *

I would be willing to help with *

Research room assistant (training provided) Library room helper Data collection Fund raising

For our personal accident voluntary workers policy please tick appropriate age bracket (s) *

10 - 50 51 - 70 71 - 85 Over 86

I will pay by *

Credit card online Direct deposit Cash / Cheque to cottage

SUBMIT THIS FORM THEN PROCEED TO PAYMENT

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Contact WFHG for website enquiries / ph: +61 2 4351 - 2211