Form
Name
Mr.
Mrs.
Ms.
Miss.
Dr.
Prefix
Surname
First Name
Middle Name
Preferred name
Preferred name (if different to first name)
Date of birth
/
Day
/
Month
Year
(You must be at least 18 years of age to join your regional corporation.)
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Home Address
Suburb
State
Postcode
State
Postal address
Postal Address
Suburb
State
Postcode
Postal / Zip Code
Are you already a member of SWALSC?
Yes
No
Which regional corporation/s do you wish to join?
Ballardong
Gnaala Karla Booja
South West Boojarah
Wadjuk
Wagyl Kaip and Southern Noongar
Yued
Please provide your family details here
(Fill out as much detail as possible in support of your application/s.)
Mother's maiden name
Surname
First Name
Mother's mother's maiden name
Surname
First Name
Mother's father's name
Surname
First Name
Father's name
Surname
First Name
Father's mother's maiden name
Surname
First Name
Father's father's name
Surname
First Name
Please provide a statement in support of your traditional connection for each of the agreement group/s you have selected above.
Statement in support of your traditional connection to the Ballardong region
Statement in support of your traditional connection to the Gnaala Karla Booja region
Statement in support of your traditional connection to the South West Boojarah region
Statement in support of your traditional connection to the Wadjuk region
Statement in support of your traditional connection to the Wagyl Kaip and Southern Noongar region
Statement in support of your traditional connection to the Yued region
Signature
Date
-
Day
-
Month
Year
Date
Submit
Should be Empty: