U3A (UWA) MEMBERSHIP FORM

ABN 32 374 014 088

Preferred Region

Title (required)
MrMrsMsDrOther

Given Name (required)

Surname (required)

Street Address (required)

Suburb (required)

Postcode (required)

Telephone (required)

Mobile

Email (required)

Emergency Contact - Name

Emergency Contact: Phone

How did you find out about U3A?

Interests and expertise I am prepared to share:
Being a guest speakerProviding Regional supportCo-ordinating coursesLeading coursesIT/AccountingMarketing/PublicityAdministrationOther

Membership Fee: $40 (1 Jan- 31 Dec) - $25 (1 July- 31 Dec) (Membership year is 1 Jan to 31 Dec)

Make cheques payable to U3A (UWA) OR

Make EFT payment to : BSB: 306 084 - Account No. 4182903 with your surname and initial as payment reference.

Please prove you are a person

OFFICE USE ONLY

$_____ Received as CashChequeEFT

Receipt No.

Region:

Date:

Registered:

U3A (UWA) MEMBERSHIP FORM

ABN 32 374 014 088

Preferred Region

Title (required)
MrMrsMsDrOther

Given Name (required)

Surname (required)

Street Address (required)

Suburb (required)

Postcode (required)

Telephone (required)

Mobile

Email (required)

Emergency Contact - Name

Emergency Contact: Phone

How did you find out about U3A?

Interests and expertise I am prepared to share:
Being a guest speakerProviding Regional supportCo-ordinating coursesLeading coursesIT/AccountingMarketing/PublicityAdministrationOther

Membership Fee: $40 (1 Jan- 31 Dec) - $25 (1 July- 31 Dec) (Membership year is 1 Jan to 31 Dec)

Make cheques payable to U3A (UWA) OR

Make EFT payment to : BSB: 306 084 - Account No. 4182903 with your surname and initial as payment reference.

Please prove you are a person

OFFICE USE ONLY

$_____ Received as CashChequeEFT

Receipt No.

Region:

Date:

Registered: