HRC MEMBERSHIP APPLICATION / RENEWAL

HRC MEMBERSHIP APPLICATION / RENEWAL
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
Date
COST:

$25.00 Annual Membership

$10.00 Students and Concession Card Holders

Please complete this form and make a payment at the Conservatorium*, or via a direct deposit into the HRC bank account with your name as the reference.

BSB: 932-000 (Regional Australia Bank)

Acc#: 100298743

Acc Name: UHCM

Reference: YOUR NAME

*Payment can be made by cash or credit card at the office or by phone.
Signature
Should be Empty: