Geelong Environment Council Inc.
A2982  Victoria


P.O. Box 4045 GEELONG VIC 3213 Tel 0352612082          Fax 0352224775   www.vicnet.net.au/~phillip/m17.htm

The Secretary, Geelong Environment Council Inc.

I apply to join, rejoin or renew 2001-2002 Geelong Environment Council Inc. membership, in the class indicated below.
I agree to be bound by the Rules of the Association for the time being in force.
 

TICK AS TO WHETHER JOINING OR RENEWING Non-member joining GEC Member renewing membership
Tick one box only please, at right ............................................. ......................................................
MEMBERSHIP
CLASS
Family 
Membership*
Single 
Membership*
 Concession* Corporate* Supporting*
Donation to
GEC Inc.
TOTAL
SUBSCRIPTION
$20.00
$15.00
$7.50
$20.00
$25.00
    
AMOUNT PAID $.............. $................. $................. $................. $................. $................ $.............
.
# # Dr/Mr/Mrs/Ms/Miss # #
(# Please circle appropriate titles)
BLOCK LETTERS PLEASE
 Given Name(s) 

SURNAME(S)

 ............................................................................ 

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Address  ........................................................................ Postcode ............................................................................
Telephone 

No.

 ........................................................................ Fax 

No.

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E-mail address ........................................................................
Special interests or skills
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(Note: Receipts sent only on request)

Signature of Applicant ..................................................................................... Date ......................................  2001