Association: |
Membership Web Form
|
Concession / Student (strike) (only if pension or
student)
Yes No (circle) |
Concession
No: |
| Title: |
Given
Name: |
Surname: |
| Residential
Address: |
| Suburb: |
Postcode: |
| Phone
Work: |
Mobile: |
Home: |
| Facsimile:
|
E
Mail: |
| Date
of Birth: __ / __ /__ (optional) |
Occupation:
|
I
HEREBY APPLY FOR MEMBERSHIP TO RADIO 4EB FM 98.1.
I FULLY SUPPORT THE ASSOCIATION'S AIMS & OBJECTIVES IN RELATION TO THE STATION AND THE
PROGRAMMING POLICIES. |
| Signature: |
Date: __ / __
/ __ |
| $25
per year for members, incl. GST 4EB FM renewal date is 1st July |
RECEIPT
NO: |
| $15
per year for concession, incl. GST 4EB FM renewal date is 1st July |
MEMBERSHIP
NO: |
| New
members and lapsed members: If you join between January and April, for an extra $10 it is
possible to extend your membership, for furtherinformation call the office (07) 3240 8600. |
| Please
charge my credit card for the amount of: $15; $25; BANKCARD; VISA; MASTERCARD; OTHER
(please circle) |
| Full
card number: |
Valid date:
__ / __ / __ |
| Name
on Card: |
Address: |
Signature of cardholder: |
- |
Please Print pages and Post to: RADIO
4EB, PO BOX 7300 EAST BRISBANE QLD 4169.
Please make out cheques or Money Orders to: RADIO 4EB FM 98.1.
You may be an associate of ONLY ONE ethnic group - Please CIRCLE your choice
hereunder:
|
