Lang Lang and District

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					Lang Lang and District
Historical Society Inc.
             Incorporation Number A0037879A




      P0 Box 8
      Lang Lang Vic 3984




                               Membership Application
                                                         (Please Print)


Mr/Mrs/Ms Names:________________________________________________________

Home Address:___________________________________________________________

____________________________________________________ Post Code: _________

Mailing Address:__________________________________________________________

____________________________________________________ Post Code: _________

Telephone Home: (______)__________________ Work: (_____)__________________

Special Interests:_________________________________________________________

_______________________________________________________________________
e.g. Books, Documents, Maps/Plans, Photographs, Oral history, Maritime history, Family History, Railways, Schools, Churches,
Post offices, General stores, Pastoral properties, Wineries, Natural history, Flora/Fauna, Geology, Recent history, etc, etc.


Signed:______________________________________________ Date : _____________


Please find enclosed a cheque for $ ______ to cover the joining and application fees.



 President: ___________________________                                         Membership Fees

 Secretary: ___________________________                                         Joining - Single/Family            $10.00
                                                                                Annual - Single                    $10.00
 Treasurer: ___________________________                                         Annual - Family                    $15.00

				
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posted:9/20/2012
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