Membership Application
Click here to print this form and forward to the MPG Office by post or fax
Annual Fees are due 1st July each year

			Malleefowl Preservation Group (ABN 80 514 097 987) PO Box 29, Ongerup, Western Australia 6336 Ph:08 9828 2007 Fax:08 9828 2018 E-mail: malleefowl.wa@wn.com.au
Membership type	Australia (incl. GST)		Overseas AUD
Single Adult	$25		$45
Family	$35		$50
Child (under 16)	$10		$30
Concession	$10		$30
Associate	$25		$45
Corporate	$110		$125
Plus
Newsletter by mail	$10		$15
Newsletter via e-mail	Free		Free

Family / Business Name	_____________________________________________________
Given Names	_____________________________________________________
Address	_____________________________________________________
	_____________________________________________________
Town	___________	State	________	Postcode	_______
Country	_______________________________
Phone Business Hours	(__) __________	Email address	_____________________________
Payment enclosed	Cheque [__]	Visa [__]		Mastercard [__]
Card Number	_______ ________ _______ ________			Expiry date	____/ ___
Name on Card	_____________________________________________________
Signature	________________________________			Date	__/___/__
Tax Invoice Required

"It's Gnow or Never"