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RATEPAYERS VICTORIA INC.

8/1248 North Road Oakleigh South 3167

Phone 03 9570 6227, Fax 9579 7300, Email jack_d@iinet.net.au

MEMBERSHIP APPLICATION / RENEWAL FORM FOR 2011-2012

Joining/Renewal fee organisation or group     s$20.00

                                                Donation gracefully accepted

I, …………………………………………………………………………….

(Print full name of person OR authorized representative)

  …………………………………………………………………………………..

(Print Address of Applicant)

do now renew/apply for membership of Ratepayers Victoria Inc

.

In the event of my admission as a member, I agree to be bound by the rules of the Association, to pay annual membership dues as determined by the Association, to uphold the aims of the Association as expressed in the Statement of Purpose and to work cooperatively with the other members.

Signature: …………………………………………...Date………../….….../……….

(Signature of applicant / authorised representative)

Member’s Contact Details   (Please PRINT clearly)

(All details are to ensure records are updated and will remain strictly confidential)

Current Postal Address…………………...………………………………………...

(Street or P.O. Box No)

Town/Suburb…………………………………….State……............P’code…........

Shire/Municipality ………..…………...……….……………………………………

Contact Name…………..………………………………………….............................

Phone: BH.…….……………………………AH: ………….…………………...

Mob: …………………………………………………..Fax:………………………………

E.Mail: …………………………………………

RATEPAYERS VICTORIA, Inc. A0040924M