Membership Application Form

Field Naturalists’ Club of Ballarat Incorporated

PO Box W328,

Ballarat West, 3350.

A0014919P ABN 13 150 403 135

Email: ballaratfnc@gmail.com

Membership Application Form

I/We (name(s) – please print)……………………………….…….………………….

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

……………………………………………………….. Postcode……….…………

Postal address if different from above…………………………………………………

………………………………………………………………Postcode………………….

Phone ……………………………. Mobile………………………………………

Email………………………………………………………………………………………

apply to become a member of the Field Naturalists’ Club of Ballarat Inc.

Please tick the category of membership for which you are applying:

Adult Member $35  Family $55 Distant Member $15 Student $15

I agree to support the purposes of the Association* and I agree to comply with the Rules of the Association and the Club’s Constitution (refer to the Club’s website at http://www.fieldnatballarat.wordpress.com).

Signature……………………………………………………..

Date……………………………………………………………

Do you wish to receive the Club’s Newsletter by email?……………………………

Do you wish to receive the Club’s Newsletter by post? ($8)…………………..

*The purpose of the Association is: to stimulate interest in natural history and to encourage the preservation and protection of the natural environment.

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