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APPLICATION FOR MEMBERSHIP
PLEASE COMPLETE THE FOLLOWING - PLEASE PRINT OR TYPE
NEW APPLICATION
RENEWAL APPLICATION [tick one]
NAME
_______________________________________________PARTNER
___________________
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LION |
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LIONESS |
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LEO |
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DIST. GOV |
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P
D G |
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[tick
one] |
ADDRESS
: __________________________________________ CITY/TOWN
___________________________________
ZIP/POST CODE
:_________ STATE/PROV :__________________ COUNTRY
: ________________________________
TELEPHONE [HOME]
(____) _________________ [WORK] (____)
_______________________
FAX
[HOME] (____) _________________ [WORK]
(____) _______________________
PHONE [MOBILE]
(____) __________________ Email
________________________________________
LIONS CLUB
: _________________________________ DISTRICT : _____
MULT.DIST. : __________
SIGNATURE OF APPLICANT
______________________________________________
SPONSORING LION
__________________________________
AMOUNT TENDERED
New Member
Joining Fee AUD $5.00
Annual Dues AUD $15.00
Associate Member Fee AUD $15.00
Membership for 3 years
(max) AUD $45.00
Please make cheque payable to AUSTRALIAN LIONS PIN
TRADING CLUB [ALTPC]
Forward to :
ALPTC Treasurer
John GILLHAM
PO Box 183
HUONVILLE Tas 7109
Phone - 03 6239 6823(B) : 03 6239 6529(H)
Email -
vsbtas@bigpond.com
Please note that all overseas remittances should be in
Australian Dollars either by bank draft or cash : personal
cheques will be accepted but a bank fee of AUD$10.00 must be
added. CASH payments may be made in equivalent US dollars.
Date of Issue
: May 2004
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