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FOMI Membership form

FOMI Membership form

Simply print off, complete and post the membership application, with the appropriate fee to:

Friends of Mud Islands Inc.
PO Box 117
Queenscliff 3225.

Membership Type (tick one)
[  ] Single $10
[  ] Family* $15

Please accept my donation of :
[  ] $20 [  ] $50 [  ] $100
other $ ___________

Enclosed is a cheque/money order/cash for: $ ___________

As part of my membership I wish to receive:
1. notification of the group's monthly activities
[ ] yes [ ] no
2. The "Mud Islands Times"
[ ] yes [ ] no

Name: ________________________________

Telephone number: ___________________

Postal Address: ______________________________________

______________________________________

Post Code: ___________

Please provide your email address, so we can easily and cheaply contact you about our activities.
Email: ______________________________________

Names of the individuals this membership covers:
______________________________________

______________________________________

I/we agree to be bound by the constitution of Friends of Mud Islands Inc. during my/our membership. Our remittance for membership is enclosed herewith.

Signature: ________________________

Date: _______________

*Family membership’s include 2 adults & all children under 19 years of age at same address. **Membership period is the standard financial year.

OFFICE USE ONLY
Date Received:
Added to membership register Y/N

 

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