PERTH PC USERS GROUP Inc.
P.O.Box 46 RIVERTON WA 6148
- Membership Application Form -
New Application[__] or Renewal[__] (Mem# ______) Change of
Details[__] (Mem#_____)
Membership Types: for
One Years membership (12 months from date of joining)
Individual *[__]$60
First Year, thereafter *$50 per annum
Family [__]$60
+ $10 per extra family member, First
Year, thereafter $50+$10
Corporate [__]$100
Up to three nominees with 1 mag + same as Individual
(Note:
Prices current at time of publishing)
Mr. [__] Mrs. [__] Ms.
[__]
Other ____ Surname: ___________________
First Name(s): ____________________________________________________
Street (Number & Name):____________________________________________
Suburb: _______________________________________
State:_____________
Country: _______________________________________Postcode:__________
Telephone Home: _________________Work:_____________________________
Fax: __________________________Mobile:
____________________________
Email Address: ____________________________________________________
Company Name: _____________________________________________________
Occupation: _______________________________________________________
Can we use these details on a mailing
list? YES or NO _____________
Where did you hear about the PPCUG?
_______________________________
Preferred name on membership card: _______________________________________________________
*Note: If your membership is in default you
will be required to add a $10 rejoining fee to your sub.
I/We hereby apply for membership New/Renewal
of the
Perth PC Users Group(Inc.) and agree
to abide by its rules
while I/We remain member(s).
Signed ___________________________________________Date
/ /
Payment details/credit
card authority
Forward to or FAX credit card
application to FAX:
"The Treasurer", Perth PC Users Group, P.O.Box
46, RIVERTON, WA 6148,
Name _______________________________________________________________
Home Postal Address ________________________________________________
________________________________________________Postcode
___________
Telephone Numbers BH:( )_______________AH:(
)_____________________
Cheque (payable to "Perth
PC Users Group Inc.") enclosed [__]
or Debit my credit card
Bankcard[__] Mastercard[__]
or
Visa [__] with $___.__
Credit Card No.
___ ___ ___ ___
| ___ ___ ___ ___ | ___ ___ ___ ___ | ___ ___ ___ ___
Expiry Date ___ / ___ Signature __________________Date
/ / 2007