Membership Form

*Full Name*
*Street Address*
*Postal Address*
*Country*
*Telephone*
*Email address*

*New Member*		*Y / N*
*Renewal*		*Y / N*
*Is this the same address as advised previously?*		*Y / N*
*Membership (amount in Australian Dollars)*		*$25*

*Signature*

Note: Payment can be made using one of the options outlined below:

1. Payment via Internet (www.paymate.com.au) to frangipanisocietyofaustralia@hotmail.com Please add $2.00 - admin fee.

2. Cheque payment to the society's address listed above

3. Direct Deposit to NAB – BSB 082 799 A/C no. 53 902 6677

Note: Credit Card payments can be made via the Internet option only

If paying by Credit Card, a $2.00 administrative fee will apply

Please complete this form and return it to the postal address above to ensure your correct membership details are registered with the society, or alternatively email this form to the email address listed above.