HMAS Perth National Association Inc
Membership Application
(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:  .................................

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 to join.  Membership for ex-PERTH personnel is free.
Associate membership is also available at AU$20 to next-of-kin and spouses of
PERTH personnel as well as any other interested person.  Associate
membership will cost AU$20 per year from 1 July to 30 June the following year.

 ... 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 to:

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

Include your cheque or money order if paying by that method.