Membership form for Wildflower Society

Please circle required membership

Wildflower Society of Western Australia (Inc)

MEMBERSHIP APPLICATION & SUBSCRIPTION FORM

Either: Print out and complete this form, then send it with payment to: The Secretary, Wildflower Society, PO Box 519, FLOREAT, WA, 6014 , Australia ; Or: If you intend to pay by Visa, Mastercard or Bankcard, save yourself postage by using our Email membership form

Membership Category	Australian Plants
	Without	With
Family	$41.00	$52.00
Single	$33.00	$44.00
Overseas	$41.00	$52.00
Concession*	$21.00	$33.00
Junior	$6.00	$17.00
Affiliated Group	$33.00	$44.00

*Students, pensioners.

Membership commences on receipt of the subscription by the Society and is renewable on each anniversary. Family, Single and Concessional membership includes our Newsletter and the "Australian Plants" journal

Mr/Mrs/Miss/Ms/Dr (Surname) __________________________

(Preferred Given Name/s)_________________________________

Address:______________________________________________________;

____________________________________________ Postcode ____________

Email address______________________________________ Phone Number______________________________

Membership type_____________________________________ Amount $_____________

Payment Method:

Cheque made payable to Wildflower Society of W.A. (Inc.)      Money Order OR
Charge to my credit card: Visa   Mastercard
Card Number:

Expiry Date: ________________ Cardholder's Name:____________________________________

Cardholder's Signature: _________________________________________