wpe1.jpg (2174 bytes) Australia Japan Society (ACT) Inc wpe2.jpg (2228 bytes)

GPO Box 1066 Canberra ACT 2601

Membership Application / Renewal

(please print and complete this form, then send it along with your payment to the address below)

Name: (Block Letters Please)

or Corporate name:

Address:

Phone: Home:

Work:

 Fax:

E-mail:

Nominees under corporate membership:

(1)

(2)

(3)

Membership Fees: (Due 1 July each year)

Ordinary $35

Student: $20

Family $40

Corporate $150

Life (one payment - 12 x Ordinary Membership Fee)

Cheques should be made payable to:

The Treasurer, Australia - Japan Society (ACT)

GPO Box 1066, Canberra City ACT 2601