Black Rock and Sandringham Conservation Association Inc.

A0021210W     Victoria

78 Abbott Street SANDRINGHAM VIC 3191

Tel (03) 9502 0060

bobwhiteway@optusnet.com.au

www.ppcc.org.au/m7.htm

The Membership Secretary, Black Rock and Sandringham Conservation Society Inc:  
I apply for new or renewed membership of BRASCA Inc. for 1st April 2001 - 31st March, 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 BRASCA Inc.	Member renewing membership
Tick one only please	......................................	.......................................

MEMBERSHIP CLASS	Family  Membership	Individual  Membership	Student/  Concession		Donation to BRASCA Inc.	TOTAL
SUBSCRIPTION	$15.00	$10.00	$5.00
AMOUNT PAID	$..............	$.................	$............	.	$................	$.............

.	# # Dr/Mr/Mrs/Ms/Miss # # (# Please circle appropriate titles)	Given Name(s)
Surname(s)	..................................................	Address	.............................................................
Postcode	..................................................	Telephone No. Home  Telephone No. Work	.............................................................  .............................................................
Fax No.	..................................................	E-mail address	.............................................................
			Receipts not sent unless requested.

Signature of Applicant ............................................................................. Date ..................................20......