Association Membership Application

Date
DD slash MM slash YYYY
Association Name(Required)
Village/Park Name & Postal Address(Required)
Street Address Address Line 2
Postcode(Required)
Contact Person(Required)
Position(Required)

e.g. HOC Secretary, President, Treasurer, other etc.
Site/Villa Number
Email(Required)
Home Phone
Mobile
Committee Members:
President(Required)
Contact Number(Required)
Secretary(Required)
Contact Number(Required)
Treasurer(Required)
Contact Number(Required)
Number of Members in your Association:(Required)
Association membership fee — $75 per annum (1 October to 30 September)
Payment Details
Number
Application By (Name)(Required)

Person making this application
Signature(Required)

If you are submitting online, please just type your name.
Date(Required)
MM slash DD slash YYYY

Date of this application
Method of Payment(Required)
- Cheque
- Direct Deposit
- Credit Card
# Reference: If paying by direct deposit please use your last name as a reference. If paying by cheque please write your Association name or your full name on the back of the cheque
Bank Account: (Bendigo) — BSB: 633-000 — Account No: 158853051
Product Name
Hidden
Coupon
Total
$ 0.00
Credit Card

MasterCard
Visa
Supported Credit Cards: MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Office Use Only
Received $
Receipt Number
Date
MM slash DD slash YYYY
Number
Date
MM slash DD slash YYYY

Committee Members: