APPLICATION FOR MEMBERSHIP
I / We wish to become member/s of FRIENDS OF HERRING ISLAND INC. (A0028229X)(ABN 71 627 163 439)

Membership

[ ]  Annual Fee   - 	$ 2.00         
         
                             
TITLE      :  __________________                         

GIVEN  NAME      :  __________________                         

FAMILY NAME      :  __________________                         

Address          :  _________________________                  

                    _________________________                  

                    _________________________                  

Telephone  :(H)     ______________                             

Telephone  :(W)     ______________                             

Telephone  :(M)     ______________                             

Email      :        _________________________

Occupation       :  _________________________                  

Special Interests: 	

 _______________________________________________                  

 _______________________________________________

 _______________________________________________
                          

Please print and complete this form, then send it to:

     THE TREASURER,
     FRIENDS OF HERRING ISLAND INC.
     10 GRACE ST,
     MONT ALBERT VIC 3127