Membership renewal form

PHILLIP ISLAND MEDICAL AND HEALTH ACTION GROUP INC.
MEMBERSHIP RENEWAL - JULY 1, 2017 - JUNE 30, 2018
Postal Address: P.O. Box 579, Cowes, Vic., 3922
Website: www.pimhag.com.au
SURNAME: (PLEASE PRINT)
DATE OF BIRTH
GIVEN NAMES:
ADDRESS: (if changed in last 12 months) STATE: POST CODE:
WHAT IS YOUR CONNECTION TO PHILLIP ISLAND? PLEASE TICK (if changed)
EMAIL: (if changed in last 12 months)
PLEASE NOTE: to receive PIMHAG correspondence, an email
address is required.
PHONE: (if changed in last 12 months)
MEMBER SIGNATURE:
DATE:
Annual subscription - $5 (due each July 1)
Amount paid: $ ___________________
If paying directly into bank account, please include surname and initial as reference.
WOULD YOU BE WILLING TO HELP WITH FUNDRAISING ACTIVITIES? YES NO
PHILLIP ISLAND MEDICAL AND HEALTH ACTION GROUP INC.
MEMBERSHIP RENEWAL - JULY 1, 2017 - JUNE 30, 2018
Postal Address: P.O. Box 579, Cowes, Vic., 3922
Website: www.pimhag.com.au
SURNAME: (PLEASE PRINT)
DATE OF BIRTH
GIVEN NAMES:
ADDRESS: (if changed in last 12 months) STATE: POST CODE:
WHAT IS YOUR CONNECTION TO PHILLIP ISLAND? PLEASE TICK (if changed)
EMAIL: (if changed in last 12 months)
PLEASE NOTE: to receive PIMHAG correspondence, an email
address is required.
PHONE: (if changed in last 12 months)
MEMBER SIGNATURE:
DATE:
Annual subscription - $5 (due each July 1)
Amount paid: $ ___________________
If paying directly into bank account, please include surname and initial as reference.
WOULD YOU BE WILLING TO HELP WITH FUNDRAISING ACTIVITIES? YES NO