Membership Form « Pine Rivers Neighbourhood Centre

Membership Form

New Membership Membership Renewal Volunteeer
Name of Applicant:
Individual / Volunteer	*
Organisation
Representative's Name	*
Address:
Street	*
Suburb	*
Postcode	*
Phone:
Home	*
Work
Mobile	*
eMail	*
Please indicate if you have an interest in, or if you would be willing to help the Association with knowledge / experience in any field.
Area/s of Interest
New members only to complete Nominated and Seconded by.
Nominated by (Member)
Seconded by (Member)

Under the Privacy Act: Your information will be stored on a membership register and will only be used for this purpose. The register is also available to other members upon request.

If you do not want your details to be available to other members please tick this box () or advise the centre.

PRNA Inc. holds Public Liability Insurance QBE Insurance (Australia) Limited $30, 000, 000.