Please fill in applicable* blanks
BEFORE YOU
PRINT FORM
 
Prime Timers Western Australia Inc.
Membership Application
 
APPLICANT
 First Name
*
 

 Surname
*
 
 Date of Birth *
CO-APPLICANT
 First Name
 Surname
 Date of Birth
     Anniversary
 
 
 Address *
 Suburb *
 Post Code *
 Home Phone Number
 Mobile Phone Number
 Email Address *
   

 
Applicant
Signature: Date:
Co-Applicant
Signature: Date:
   
Membership Dues: Single $30.00 per financial year
Couple $45.00 per financial year per household (2)
Mail your application form along with your cheque or money order  Please do not send cash
To: Prime Timers Western Australia Inc. P O Box 829, Mt Lawley 6929
Payment in cash can be made at monthly meeting

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