HUGUENOT SOCIETY OF AUSTRALIA INCORPORATED

(incorporated under the NSW Associations Incorporation Act 1984)

Date __________________

Membership Secretary
Huguenot Society of Australia Inc
20 Spring Street
BIRCHGROVE NSW 2041

2009 MEMBERSHIP APPLICATION / RENEWAL

(Membership is for a calendar year)

I/We wish to become a member / to renew membership of the Huguenot Society of Australia Incorporated and agree to be bound by its rules and regulations. See our Internet Web Site or request a copy.
My/our cheque/AMO payable to "Huguenot Society of Australia Inc" is enclosed for $

My/our details are as follows: Please PRINT clearly.

	Column 1: Single Subscription $25	Column 2: Joint Subscription $35
For a Joint membership please put name of 1st member under Column 1, and name of 2nd member under Column 2	please tick appropriate box Mr Mrs Ms Miss Dr Rev Other (please specify) _________________	please tick appropriate box Mr Mrs Ms Miss Dr Rev Other (please specify) _________________
First given name or name you wish to be called by
Surname
Huguenot family name(s) with which connection claimed & research interests See Member Service below **
Mailing address (Only one postal address for a Joint membership please)
	[State][Post Code]
Phone No.	()
E-Mail address	Please PRINT legibly using correct case (upper/lower).

**Member Service: The society publishes an annual list of members' names, addresses and Huguenot connections or research interests, which is ONLY sent to the society's members. Please tick ONE box:

YES, PLEASE INCLUDE MY NAME, POSTAL ADDRESS & RESEARCH INTERESTS ON THE LIST

NO, PLEASE DO NOT INCLUDE ANY OF MY INFORMATION ON THE LIST