Western Australia Study Group
Application for Membership

To PO Box 423 Date_________________
  Claremont  
  Western Australia 6910  

All details provided are strictly confidential and will NOT be revealed

Full Name
Residential Address (mandatory)
 
 

Address for correspondence
 
 
Phone Fax
 
Please nominate two referees in support of your application.
 

Name
Address
 
Phone
 
Name
Address
 
Phone
 
Please list any other relevant societies to which you belong
 
 
Your Special Interests: Western Australia in details; others
 
 
Applications, when received by the Secretary, will be tabled at the next regular meeting and processed at the subsequent regular meeting