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Dingo Sanctuary Bargo
Australian Native Dog Conservation Society
590 Arina Rd (PO Box 91) Bargo NSW 2574
Website: www.dingosanctuary.com.au  
E-Mail:dingosanctuary@optusnet.com.au
ABN: 64001407352    
Incorperated 1976         
    Reg Charity CFN 10177
   
Tel: (02) 4684 1156
Fax: (02) 4684 1856
Membership Renewal Form
 
Amount
Membership with newsletter AU$40.00
................
Family Membership (two people at same address) with one newsletter AU$50.00
................
Donation ($2.00 and over are tax deductable)  
_________
 
Total
_________

NAME: _____________________________________________________________________________________________
STREET: ____________________________________________________________________________________________
SUBURB/TOWN: ____________________ CITY: ___________________________ POST CODE: __ __ __ __
E-MAIL: _________________________________________________________________________________________
TEL Home: __________________________ TEL Bus: ________________________ FAX: __________________
MOBILE: ________________________________________________________________
I, the above wish to apply for membership of the Australian Native Dog Conservation Society Limited. As a member of the above society, I agree to abide by the Society's policies as described in the Memorandum and Articles of Association, and Rules and Regulations enacted from time to time. I further agree to make no commitments or agreements in the name of the Society, or release publicity of any kind to the media without approval from the Board.

SIGNED: ________________________________________________________________

Please make cheques payable to: Australian Native Dog Conservation Society

I enclose my cheque/money order for $...................in payment
                                    OR
Please charge my Mastercard/Visa/Bancard/American Express
My full card no. is: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Valid from: __/__  Until end: __/__
Name on card: ___________________________________________________
Address on card: _________________________________________________
___________________________________________ Post Code: __ __ __ __

Signature of card holder: _____________________________

Please send payment in Australian Dollars. Thank You.

Office Use Only: Receipt Number:________________________ Date: __/__/__ Approved: __/__/__

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