Application for Membership
South East Queensland Group of the Historical Radio Society of Australia.
(Inc. in Victoria A22838K)

I ............................................................................................................................................................................
(full name of applicant)

of ..........................................................................................................................................................................
(Residential Address)
Desire to become a member of the South East Queensland Group of the Historical Radio Society of Australia (Inc.) In the event of my admission as a member, I agree to be bound by the rules of the Society being in force at the time.

Signature: ............................................................ Date: ...........................

I enclose a Cheque/Money Order for ( Single $20 / Couple $25 ) payable to South East Qld Group HRSA for one years dues. (The membership year is from July 1st to June 30th)

Phone Home: ........................................ Work: ........................................ Mobile: ........................................

Partner's Name (If Couple Membership): ......................................................................................................

Email ...................................................................................................................................................................

Web Site ............................................................................................................................................................

Occupation .......................................................................................................................................................

Background/Experience in Radio/Electronics:

..............................................................................................................................................................................
Special Interests in Radio: (check boxes)
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List other radio Interests:......................................................................................................................................

When we publish a list of members ( Address not published ) may we disclose your
Phone number and/or Email address
(The SEQG members list distribution is restricted to current SEQG members, to allow members to contact each other.)

Please send this application form and remittance to:
SEQG Membership Secretary, 49 Barwood Street, Newmarket Qld 4051.

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