TITLE (Mr., Mrs., Ms. Miss, Dr., etc):

NAME:

ADDRESS:

POSTCODE:

PHONE: FAX:

Email:

Date:

I, hereby apply for membership of the Australian Lebanese Historical Society and agree to abide by the rules of the Society.

Signature of Applicant:

Joining Fee ............................ $25
Annual Membership Fee ........ $25
Donation .......................
Total .............................

Please make cheques payable to Australian Lebanese Historical Society and post application to: