Membership Form 2016-2017
Personal Details:
Name(s):
Home Address:
Postal Address:
Email:
Daytime phone:
Please Circle: New member / Renewing member
Membership Category:
Youth ($10) Concession ($25)
Individual ($50)
Family ($70)
Business ($150)
Community Org ($60)
Life ($500)
Form of payment:
Cash Cheque Credit Card EFT P/Pal
Card Number: _________________________
Expiry Date ___ / ___
EFT PAYMENT details:
BSB - 633 000 Acct No – 132477324.
Acct Name - Mt Alexander Sustainability Group Inc.
Reference – your Surname followed by Initial Automatic Membership Renewal:
Yes! I would like to have my membership automatically debited from my credit card
annually until I notify otherwise.
Donations: ANNUAL
Yes! I would like to make a tax-deductible donation each time I automatically renew my
membership for the amount of:
$25 $50 $100 $200 my choice $_____ ($10 minimum)
Donations: MONTHLY
Yes! I am interested in making a monthly donation to support MASG in project work in
Mount Alexander Shire for the amount of:
$25 $50 $100 $200
my choice $_____ ($10 minimum)
Signature: Date: ______ / ______ / 20_____
Please return this form with your payment to:
MASG
PO Box 1043, Castlemaine, 3450 /
[email protected]
This document is obtaining personal information as defined by the Privacy Act 1988
(Cwth) (the “Personal Information”). By returning a completed document you agree that
MASG Inc. may collect personal information to process your membership/donation.
Office use only:
Date Received: _____ / _____ / 20____ Receipt No.: Bk _____ # _____
Date entered
on Database: ___ / ___ / 20____ MailChimp: _____ Letter New Memb list
VOLUNTEER with MASG: Would you like your name put on our Volunteer
Register? Yes / No
In which areas are you particularly interested or would like to be involved:
PLEASE CIRCLE
Energy Efficiency
Renewable Energy
Climate Science & Technology
Education in community
Advocacy on sustainability
Local food production
Housing & Built Environment
Waste reduction
Climate change adaptation
Stalls at Markets & Festivals
Working in MASG Office
Wash Against Waste Trailer
Fundraising
Community Solar
ABOUT YOU:
What is your occupation?
Please list any qualifications, skills or experience that might be useful to MASG.
Please tell us your previous volunteer experience?
Are you a student? Please list
your area of study. Availability – please CIRCLE when you can work with us
Weekdays Weeknights Occasional Weekends