BIG SCRUB RAINFOREST LANDCARE GROUP
ABN 44 919 192 078
Application for Membership

I (name) ............................................................................

of (address) .......................................................................................................................................................

hereby apply to become a member of the Big Scrub Rainforest Landcare Group Inc.

(incorporated under the Associations Incorporation Act, 1984) In the event of my

admission as a member, I agree to be bound by the rules of the association for the

time being in force.

Contact phone no:: ..............................Email Address: ..............................................................

Please return this form to John Leedom, BSRLG, 194 Kings Rd. Federal, NSW 2480,

together with a cheque for your membership fee (due January each year) selected from

the following options:

.... $15 for annual individual or

.... $10 for concessional individual annual membership (students and pensioners) or

.... $20 for family annual membership or

.... $60 for 5 years' individual membership or

....$80 for 5 year's family membership or

....$300 for life membership

If you require a receipt, please place a tick on this line....

Your receipt will be sent with the next copy of the Newsletter which comes out three times a year

My e-mail address is:....................................................

My telephone number is:...............................My fax number is:...............................................................

I wish to pay by

Cheque

Money Order

Credit Card

Cash

(Please circle your choice)

Please make cheques and money orders payable to the BSRLG. If paying by credit card please provide the following details:

MasterCard

Visa

Bankcard

(Please circle the appropriate card)

Card No:

Card Expiry Date: ____ / ____/ ____

Name on card: ___________________________________Cardholder's signature: _________________________