TUGGERAH LAKES U3A Inc

APPLICATION FOR NEW MEMBERSHIP

for year ending 31^st December 2012

Please Print and return Application together with fee to:

The Treasurer,

Tuggerah Lakes U3A Inc.,

 4 Sir Joseph Banks Drive,

Bateau Bay, NSW 2261

Mr/Mrs/Miss/Ms/Dr: ………………..

First Name:              …………………..………Preferred 1^st Name……………. ……….

Surname:                 ………………………………………………………………………..

Address:                  ………………………………………………………………………….

…………………………….…………………………………………..  Postcode: .……….

Telephone: Home:  ……………….…………….  Business: …………………………….

E-mail address:      …………………………………………………………………………

Emergency contact number (if any):  ………………………………………………………

I hereby apply for New Membership of Tuggerah Lakes U3A Inc

and agree to abide by the laws of the organisation.

Signature ……………………………………………          Date: ………………………..

Occupation before retiring …………………………………………………………………

Would you be prepared to act as a course leader? ……………………………………

State in which field …………………………………………………………………………

Other U3A membership (if any) ………………………………………………………….

Membership year is 1 January to 31 December

ANNUAL MEMBERSHIP FEE:  $20

(reduced pro-rata for New Members by $5 for each Term that has already expired).

Office use only:    

Membership No

Receipt No

Date

_