186 Wallace Street Braidwood NSW 2622
PO Box 145 Braidwood NSW 2622
Phone: 02 4842 2310
Email: help@braidwoodmuseum.org.au
www.braidwoodmuseum.org.au
APPLICATION FOR MEMBERSHIP
Name: ……………………………………………………………………………………...
Address:…………………………………………………………………………………….
……………………………………………………………………………………...
Phone/s:………………………………………………………………………….............
Email:……………………………………………………………………………..................
Membership Fee: [PLEASE INDICATE in the space provided ]
1 Year - □ $10 Single or □ $15 per Family OR
5 Years - □ $40 Single or □ $60 per Family
Paid: Cash…………..……Cheque…………………….Direct Deposit………….
Please pay membership into account listed below:
[ Account Name: Braidwood & District Historical Society - Direct Deposit: BSB: 633-000 Account: 132233354 ]
Acknowledgement: I HEREBY APPLY TO BECOME A MEMBER OF THE BRAIDWOOD AND DISTRICT HISTORICAL SOCIETY INC. I AGREE TO BE BOUND BY THE RULES OF THE SOCIETY.
Signature of applicant …………………………………………………………..
Date:………………………………………..
[Office use only – Entered into record - …......./…......./…....... By………………]