APPLICATION FOR MEMBERSHIP Title

Given Names

Family Name

Preferred Name for Badge Sex M/F

Year of Birth

Address

Post Code

Suburb

Email Address

Home Phone

Mobile Phone

Previous Occupation(s)

Interests / Hobbies

1st Emergency Contact Name

Relationship

Home Phone

Mobile Phone

2nd Emergency Contact Name

Relationship

Home Phone

Mobile Phone

Emergency Doctor [To print on the back of the Member’s Badge]

Doctor’s Phone Number

If you are a current member of another U3A, please state which one

If you are interested in volunteering your skills and experience, and would like to contribute to the running of U3A Wheelers Hill, please place X in the box below the appropriate area Class Computer / Equipment Tutor Office Duties Committee Assistance Data Entry Maintenance

MEMBERSHIP FEE INFORMATION If pay by cheque, please make payable to U3A Wheelers Hill Membership Fee Single $50 Couple $80 ($40 + $40) Associate Single $35

Category Full Associate Tutor

Paid by Cash Cheque EFT BSB 013271 Acc No. 219979241

Paid

Date

$

U3A Wheelers Hill Inc., 1 Jacksons Road, Mulgrave VIC 3170 Website: http://www.u3awheelershill.com Email: [email protected]