U3A (UWA) MEMBERSHIP APPLICATION FORM

Title (required)
MrMrsMsDrOther

First Name (required)

Last Name (required)

Preferred First Name

Street Address (required)

Suburb (required)

Postcode (required)

Phone 1 (required)

Phone 2

Your Email (required)

Preferred region?Joondalup (Kallaroo)WannerooNorth Coast (Hamersley)Mid North (Dianella)Swan Hills (Midland)Western SuburbsLesmurdie HillsS E Metro (East Vic Park)S W Metro (Melville)Rockingham and Districts

How did you hear about U3A?

Have you been a member of U3A (UWA) before?
If "No", leave blank. If "Yes", which year?

What are your interests and hobbies? Please list

The quarterly U3A (UWA) Inform newsletter is emailed to members. Do you require a mailed paper copy of this newsletter? YesNo

Membership Fee: $40 - (Membership year is 1 Jan to 31 Dec)

Pay by Direct Bank Deposit: BSB: 306 084 Account No. 4182903 - Account Name: U3A (UWA)

Please identify bank payment with last name and initial

Please prove you are a person

Office Use Only

$ Recd by EFT

Region

Receipt No.

Date

Registered by

U3A (UWA) MEMBERSHIP APPLICATION FORM

Title (required)
MrMrsMsDrOther

First Name (required)

Last Name (required)

Preferred First Name

Street Address (required)

Suburb (required)

Postcode (required)

Phone 1 (required)

Phone 2

Your Email (required)

Preferred region?Joondalup (Kallaroo)WannerooNorth Coast (Hamersley)Mid North (Dianella)Swan Hills (Midland)Western SuburbsLesmurdie HillsS E Metro (East Vic Park)S W Metro (Melville)Rockingham and Districts

How did you hear about U3A?

Have you been a member of U3A (UWA) before?
If "No", leave blank. If "Yes", which year?

What are your interests and hobbies? Please list

The quarterly U3A (UWA) Inform newsletter is emailed to members. Do you require a mailed paper copy of this newsletter? YesNo

Membership Fee: $40 - (Membership year is 1 Jan to 31 Dec)

Pay by Direct Bank Deposit: BSB: 306 084 Account No. 4182903 - Account Name: U3A (UWA)

Please identify bank payment with last name and initial

Please prove you are a person

Office Use Only

$ Recd by EFT

Region

Receipt No.

Date

Registered by