5514085 - Clone of VOX FM Membership Application

MEMBERSHIP APPLICATION

NB: All members must be over 16 years of age. Members under 18 years of age must join with their parents or as a nominated representative of a group or organization
Group / Corporate
Company Name
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Post Code
Mobile*
Mobile Number
Home Phone
Home Phone Number
Email*
example@example.com
Date of Birth*

DayMonthYear
Date of Birth
I wish to apply to be a member of Illawarra Community FM Broadcasters Ltd, (Trading as VOX FM) and if accepted I agree to be bound by the constitution and policies of the company. I agree to visit VOX FM in person during Office Hours to confirm my identity with one of the below options:
Proof of Identity*
Select your Proof of Identity to be confirmed on the day of visit.
Sign this form*
By writing your Full Name you agree to Digitally Sign this form.
Date*

DayMonthYear
Date
Payment Options*

CashBank DepositCredit Card
VOX FM requires full payment of Membership Fee before being considered for Board's Approval. Please use below details for Bank Deposit:

BSB: 814-282

Acc No.: 4216-7481

Payment Ref.: Your Surname
VOX FM requires full payment of Membership Fee before being considered for Board's Approval. For Cash payment visit us in person at:

11 Tallagella Street

Unanderra NSW

EFTPOS facility on site available (1.9% Surcharge applies)
Membership type*

Concession - $15.00Individual - $35.00Family - $50.00Group - $120.00Corporate - $130.00
Merchandises
T-Shirt - S ($30.57 AUD)
T-Shirt - M ($30.57 AUD)
T-Shirt - L ($30.57 AUD)
Donate
Subtotal (Hidden)
Total (Prices include 1.9% Surcharge)

prevnext( X )
AUDDescription

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

Merchandises