Nambucca Valley Arts Council Application Form

MEMBERSHIP APPLICATION FORM

Print this Application then fill it in by hand. Mail form and payment to
Nambucca Valley Arts Council, P.O. Box 94, Nambucca Heads 2448

The following application covers (please circle as applicable)

An individual $12 A family or couple $16 An organisation $25

Member Name(s) ______________________________________________________

Postal Address ________________________________________________________

Phone ____________________

E-mail Address (write clearly) ____________________________________________

Please write the names of person(s) covered by this Membership. Kindly note that a family is an adult individual or couple and any dependent children living at the same address.

__________________________________ __________________________________

Signature _____________________________ Amount enclosed $ _____________