U3A (UWA) APPLICATION FOR MEMBERSHIP

Preferred Region

Title (required)
MrMrsMsDrOther

Preferred First Name

Last Name (required)

Street Address (required)

Suburb (required)

Postcode (required)

Phone 1 (required)

Phone 2

Your Email (required)

Occupation

Emergency Contact - Name

Emergency Contact: Phone

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)

For EFT payment: BSB: 306 084 - Account No. 4182903

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) APPLICATION FOR MEMBERSHIP

Preferred Region

Title (required)
MrMrsMsDrOther

Preferred First Name

Last Name (required)

Street Address (required)

Suburb (required)

Postcode (required)

Phone 1 (required)

Phone 2

Your Email (required)

Occupation

Emergency Contact - Name

Emergency Contact: Phone

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)

For EFT payment: BSB: 306 084 - Account No. 4182903

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