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 ............................ $30
Annual Membership Fee ........ $30
Donation .......................
Total .............................

Payment Options:
1. Cheques/Money Order payable to Australian Lebanese Historical Society
2. Direct Debit (EFT): BSB: 032152 Account: 134813 Westpac Coogee NSW Account Name: Australian Lebanese Historical Society - Ref: select a random 4 digit number and include on your application form or email.

Post application to:
Treasurer, Australian Lebanese Historical Society, PO Box 712 Coogee NSW 2034