HMAS Perth National Association Inc


Membership Application
(Please print this page and complete the printed form for mailing)


Surname: .......................  First: .....................  Init: ......

Preferred (or nick) Name:  .............................

Street:  ....................................................................

Suburb:  ........................... State: ............

P/code:  ............ Country: .........................

DOB:     ........................

Phone(home):   ........................ (inc A/C)

Phone(mobile): ........................ (inc A/C)

Official No: ...........................  Rank/Branch: .....................

Partner's First Name:  .................................

I would prefer to receive my PUNDIT (newsletter) by E-Mail  .....Y  .....N
(please tick)

Time on PERTH:
1.  From (mm/yy): .................... To (mm/yy): ....................

2.  From (mm/yy): .................... To (mm/yy): ....................

3.  From (mm/yy): .................... To (mm/yy): ....................

E-mail Address: .......................................................

Membership costs AU$20 per year, from 1 July to the following 30 June.
Membership for ex-PERTH (1) personnel is free
Associate membership is also available at AU$20 to next-of-kin and spouses
of PERTH personnel.

..... I have made a payment of AU$20.00 by DIRECT DEPOSIT, to:
HMAS Perth National Association
BSB #   062208      Acct #   10001173
or
Please find enclosed a ... Cheque    ... Money Order for AU$20.00
being for one years' membership of the Association
Please make payable to:  HMAS Perth National Association

Please note that if you use DIRECT DEPOSIT, you must include your Name
and the reason for payment  (eg membership)

Please complete this form and mail, together with your cheque or money order to:

The Membership Secretary
HMAS Perth National Association Inc.
PO Box 626
MERIMBULA   NSW   2548