The Australian Hazara Association WA Inc Membership Form
Perth Western Australia
Name
*
First Name
Last Name
Gender
*
Male
Female
Other
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
City
State / Province
Postal / Zip Code
Membership Type
*
Single
Family
Membership Category
Please Select
Associate
Ordinary
Membership Fees
*
Single Monthly Fee $50
Single Lifetime Membership $2500 (One time Payment)
Family Monthly Fee $100
Family Lifetime Membership $5000 (One time Payment)
Direct Debit Detail
Signature
*
Date
*
-
Day
-
Month
Year
Date
Submit
Submit
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