Please complete the following:
	Title		First Name		Surname

	________________________________________________________________

	
	Address_________________________________________________________

	
	________________________________________________________________

	
	Postal Address__________________________________________________
	(If different to residential address)

	
	________________________________________________________________

	
	Phone No. Home__________________________________________________

	  	  
		  Business______________________________________________

	  	  
		  E-mail________________________________________________

	  	  
		  Fax___________________________________________________

	
	Payment Details:		 Fee		 Please Tick
			     	      (Inc GST)	       Applicable Box

	Single  (including guest)      $36.00		    

	Single Membership	       $20.00