New Membership Application

New Membership Application
Coolum HeARTs Inc

Shed 5, Cnr Elizabeth St & Sunrise Ave

Coolum Beach

QLD 4573

PH: 0478646330
Application for Year*
I ____________________________ and __________________________ being financial members of Coolum HeArts Inc nominate
First Name
Last Name
Address

Street Address

Street Address Line 2

CityState

Postal Code
Email
example@example.com
Home Number
Mobile Number
Emergency Contact details

First NameLast Name
Emergency Contact mobile
Membership Fee:

$45 Full Member$100 Agency Member
Payment options: Cash/Cheque/Direct Debit

Bendigo Bank: BSB 633000 Account: 155000938

(Please use your surname as the reference)
Signed Proposer
____________________
Signed Seconder
___________________
Paid*

YesNo
Date Paid

DayMonthYear
Date
Signature Applicant
Would you like to receive notifications/newsletters?

YesNo
Do you give your permission for Coolum HeARTs to use images of you for promotion purposes?

YesNo
Date

DayMonthYear
Date
Thank you!

Coolum Hearts Inc holds a $20 million Pulic Liability Insurance policy with AON.
Should be Empty: