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					            Shellharbour City                                                  Membership
   Community Drug Action                                                    Application/Renewal
                   Team Inc                                                        Form



Please complete this form in block letters.

Applicant’s details: (Ms/Mrs/Miss/Mr/Other…………)


Given name: ……………………… Family name: …………………………………


Organisation (if applicable): …………………………………………………………


Postal address: ……………………………………………………………………….


…………………………………………………………..Postcode:…………………..


Telephone (Day): ………………………… (Home): ………………………………


(Mobile): ………………………… E-mail: ………………………………………..

Are you under the age of 18?                       Yes                No

Signed: …………………………………………… Date:……………………………


                       Membership of Shellharbour City CDAT is free.

   This information will enable us to keep a record of your membership on a
       database so that we can keep you informed of CDAT's activities.

                        When completed, this form should be sent to:

                                  The Secretary
                              Shellharbour City CDAT
                                 C/- PO Box 155
                       SHELLHARBOUR CITY CENTRE NSW 2529
Privacy note: your personal details are required solely for the purpose of communicating with you about Shellharbour
City CDAT and, except for members of the Management Committee or delegated sub-committees, will not be
revealed to any other person.

				
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