English Springer Spaniel Club of Victoria Inc
Inc No A0013758G
(Affiliated with the Victorian Canine Association)
Membership Application/Renewal Form for Year 2009/2010
Membership is due for renewal by 30th September 2009
Type of Membership required………..(please tick appropriate square)
Junior (Under 16 years)…………………………………………………$10.00 □
Single (1 person only)……………………………………………………$15.00 □
Dual (2 people only)……………………………………………………...$20.00 □
Donation…………………………………………………………………............. □
Name:……………………………………….. VCA Membership No/s:……………………
(If a member)
Address: (If new or changed)………………………………………………………… …………….
....................................................................................................Post code:…………………
Telephone: Home:…………………………….. Business:……………………………
Mobile:……………………………. Fax No:………………………………
Electronic: Email Address:…………………………………………………………….......
Please tick box if you wish Club newsletters & notices to be sent electronically to this address □
Kennel web page (if available):……………………………………………………………..
Signature:………………………………………………………Date: ………………………
Please make cheques payable to: English Springer Spaniel of Vic Inc
Post To: The Secretary, PO Box 352, Wallan Vic 3756
For Queries, phone: 0433 937 842
Office Use Only:
Amount Received: $................... Date received: …………… Passed to Treasurer:………………
Cheque:………………. Postal Order………………. Cash………………Internet………………….
