VCPS Membership Application

 

To: Peter Bloem

VCPS Membership Secretary

1 Pollard Place

Sunbury  Vic  3429

Australia

 

 

Membership Type:

New Member        Renewal        Change of Address
$25 Membership Donation:

Enclosed         Direct Deposit (copy of receipt attached)

Not Applicable (change of address only)

Full Name:

Current Address:

Phone:

B.H.

A.H.

Mobile

Email Address:

Email Forum

Do you wish to be automatically enrolled in the VCPS email forum?                    Yes                       No

(See the forum page for more details)

Where did you hear about the VCPS?

(New members only)

 

Credit Card Details

(not available where applicant resides within Australia)

No       

Expiry Date 

Card Type:                 Visa               MasterCard

 
Privacy Consent:

I consent to my personal details (as above) being shared with other VCPS members for communication purposes only.  

(They will not be disclosed to any third party.)

See the VCPS Privacy Policy for more information.

 

 

Signature & Date:

 

 

______________________________________________________

     Note: Membership is subject to approval by the VCPS Committee.