Membership Application

Name*

First NameLast Name

Postal Address*

Address Line 1

Address Line 2

CityState

Postcode

Home Phone Number

Please enter a valid phone number.

Mobile Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Nominators

If you are unable to complete the first and/or second nominator details below, leave blank

First Nominator

First Nominator Contact Details

Second Nominator

Second Nominator Contact Details

If accepted as a Member of Port Stephens FM Radio Incorporated, I agree to abide by its Constitution, Policies and Procedures and related guidelines.

Signature*

Member ($5)

Donation

Port Stephens FM is a community based not for profit organisation. Any additional support you can provide would be greatly appreciated.

Total

Credit Card (online)Bank transfer (EFT)Cash (please pay at the station adminstration office)

EFT Payment Details:

Greater Building Society, Salamander Bay

BSB: 637 000 Account Number: 781 743 666

When paying by EFT, put your name as a reference on the transaction.

Credit Card Payment

AUDDescription