NZ & Asia/Pacific - A$15 Rest of world - A$20 |
Please complete the 8 items below to confirm your membership details and return it with your subscription payment/payment advice (e.g. Bankcard, Mastercard or Visa). This will allow us to update our records where necessary.
* Overseas members must include the relevant airmail postal costs with their subscription.
** A 2% surcharge will be added if paying by Card.
Printable .pdf version of this form - CLICK HERE
| 1. Given name(s): | First name: | Surname: | Mrs / Miss / Ms / Mr / Dr |
| 2. Address: | . . | See Membership types below. | |
| 3. Contact: . | email : | Mobile Phone: | Home Phone: |
| 4. Membership : (Please tick) | . | Membership A$35 p.a. ( . . ) (Posted Bromeletter) | Membership A$25 p.a. ( . . ) (emailed Bromeletter) |
| *For posted Bromeletter add - - - > **If paying by Card, add 2% surcharge | Australia Post Free ( . ) | Asia/Pacific Airmail + A$15.00 ( . . ) | Rest of World Airmail + A$20 ( . . ) |
| 5. Payment : | Cheque ( . ) | Overseas Draft ( . ) | Cash ( . ) |
| (Please tick) | Bankcard ( . ) | MasterCard ( . ) | VISA card ( . ) |
| Postal Order ( . ) | Other : | ||
| 6. Card Details : | Cardholder name: | . . | |
| Card number: | Expiry: . | ||
| 7. Card Holder Signature | Signature : | ||
| NAME USE AUTHORISATION: Under the provisions of the Federal Government Privacy Act, use of names and references to private details, such as illness, holidays, birthdays and items of a similar nature, such as those contained in Members' Update, may only be published with the written permission of the person concerned. This is a government requirement, not this Society's. Do you agree to having such personal information included in the Bromeletter? |
| 8. Name use authorisation | Yes. _____ | No. _____ | Signature. |