Membership Application

Use the form below to join or renew your membership online. To join by phone call the Trust: Monday — Friday during normal business hours on 03 6344 6233.

Personal Details
Title:
Your Name:
Name of Second Cardholder: (for family memberships)
Address:
Postcode:
Phone Bus:
Home:
Email address:

Membership & Extras
Renewal:
Membership number: (if renewing)
Membership Fees:
Gift: (to support the Trust’s community and education programs — all donations $2 or more are fully tax deductible)

Payment Details
Total amount due:	$55.00
Card Type:
Card Number:
Cardholder’s Name:
Expiry Date	/
Automatic renewal option:	Please renew my membership annually at this level using the above credit card information.
Please type the 5 numbers from the image on the right into the field next to it.