Voluntary Euthanasia Society of New South Wales
Membership Form
  Title eg Ms, Mrs,Mr, Dr etc
Full Name
Partner's Name
Address
Suburb/Town   Post Code: State: If Overseas write Country
Telephone
Home:   Mobile:  Work:   Occupation: 
email
   Helps reduce administration costs
Membership
Renewing    New member
Age Group






Research
How did you hear about the Society?
Donation
I would like to donate to the Society the following amount: $
Payment
Mastercard      Card No.  - - -

Exp Date: /
Total to be debited $ Card Holder's Name:

Signature: _______________________________________________________

Ageement I would like to join the Voluntary Euthanasia Society of New South Wales and will abide by its constitution and by-laws.

              

When completed you can Fax the form to:
(02) 9211 1498 		Post the completed form (with your cheque) to:
VESNSW, PO Box 25 BROADWAY NSW 2007
Office Use Only
Receipt Number:   Date:   Amount: $
Member Number:   Docs Sent:   D/B: