Wootton Community Network - Membership Application Form

Membership Application

(CONFIDENTIAL – one form per member)
I apply to become a member of the Wootton Community Network Inc.
I understand that the aims of the association are

• to see the local area prosper once more, with improvements to existing services and the creation of

employment opportunities in an environment of community not isolation.

• to enhance the lives of people living within the local community.

• to serve as an example to other small isolated communities.

• to develop a sense of pride within the community.
The following information is submitted for consideration of my application:
Name *

First Name Last Name
Local Address *

Street Address

Street Address Line 2

Suburb State

Postcode
Postal Address (if different from local address)

Street Address

Street Address Line 2

Suburb State

Postcode Country
Phone *

Area Code Phone Number
E-mail *
Website (if applicable)
This is my/our: *

Farm Home Business Weekender
Would you like to volunteer to help at some time? *

Yes No
If yes, please list the skills that you would like to share with Wootton Community Network
ANNUAL MEMBERSHIP FEE: $12.50

Secretary will confirm via email if membership is accepted
Payable by direct deposit to:

Wootton Community Network Inc.

Regional Australia Bank

BSB: 932000

Account: 500023558

Reference: “WCN20” and your name

Please email when paid to notify the Treasurer brushturkey@live.com.au

Alternatively, you can post a cheque, pay by cash or card at a meeting or event at the Brush Turkey Café.
I agree that my contact details will be supplied to other members for networking purposes. *

Yes No
Your Signature *

Clear
Should be Empty: