COUNTRY
NETWORK
www.countrynetwork.com.au
MEMBERSHIP APPLICATION
Country Network is incorporated in NSW Reg. No. (Y2063541). The following is required Membership
information. Your privacy and confidentiality will be protected by Country Network.
Section A: Applicant details. Single or Joint Membership. (For our confidential membership records only.)
(1) Surname ................................................... Given Name(s) ...........................................................................
(2)Surname .................................................... Given Name(s) ...........................................................................
Home address (NOT a P.O Box) No:/Street .......................................................................................................
Suburb/Town .................................................................... State/Territory .............................. P/C ...................
Confirmation of Identity: (you must complete at least one of the following requirements):I/We are known to this Country Network member: ..........................................................................................
I/We have attached a copy of my/our identification, (drivers license, passport, etc.)
Details: ................................................................................................................................................................
Section B. Members’ details. For publication in our members list, and for display on your profile on the
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Country Network Website. Both are only available to members. (* denotes required information.)
(1) * Given Name ....................................................... (2) * Given Name ......................................................
Surname ................................................................
Surname ................................................................
* Date of Birth ............/............/....................!
* Date of Birth ............/............/....................
* Contact Details: (At least one method of contact must be provided for members. Please give as many as
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you are comfortable with.)
Address:
Or: No./Street (or P.O. Box) ........................................................................................
(‘X’ if as in section A.)
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Town/Suburb ......................................................................... State .................... P/C ....................
Mobile (1) ....................................................................
Mobile (2) ...........................................................
Email (1) ......................................................................
Email (2) .............................................................
Interests (1) i ...............................................................
Interests (2) i ......................................................
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ii ...............................................................!
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ii ......................................................
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iii ...............................................................!
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iii ......................................................
Home Phone (
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If hosting, bedding available to guests is: Single
Smoking:
No
Outside
I/We are able to:
Twin
Double
Host
Guide
Or share host’s bed
Inside
You can change your profile at any time in the “members only” area of the Country Network website, or by
contacting the Webmaster with your changes.
Section C:
I heard of Country Network through ...............................................................................................................
I am a member of other gay groups (names) ...................................................................................................
Section D: Fees.
Annual subscription: Subscription is for a financial year from 1st July to 30th June of the following year.
New members will be financial till the 30th June of the year following joining.
Internet or Postage?
Internet only membership is available to members with internet access as demonstrated by listing an email
address above.
The Postage Premium is payable by members without access to the Internet to cover the cost of printing and
posting out the Magazine and lists of members. This option is also available to members with unreliable
Internet connections.
Single or Joint Membership with Internet only option:
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Single or Joint Membership with Postage Premium:
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Section E: Payment. (Please tick the relevant box.)! !
ABN 58 403 175 652
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Direct Credit, or!
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Self Deposited Cash or Cheque!
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(Please arrange for your name to appear on our bank statement.) !
$30.00
(Please tick the relevant box.)
$45.00
Commonwealth Bank: BSB 065 521
Account Number:!
1009 6483
Account Name: Country Network
Date Paid ........../........../....................!
Credit Card (MasterCard or Visa only.)
Card Number
Expiry Date
Name (as on the card) ........................................................................
Amount $ .......................
Cardholder’s Signature .......................................................................!!
Date ........./........./...........
Cheque or Money Order (Payable to “Country Network” and sent in with this application.)
Please note: Cash or cheques can be paid in at any Commonwealth Bank branch using the account information above.
If this is convenient for you, it would be appreciated by our volunteers.
Section F: Declaration.!
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(Signatures, please)
I/We hereby apply for membership of Country Network
I/We declare that I/we am/are over the age of 18 and will abide by the rules and spirit of Country Network
(1) ............................................................................................................... Date ........../........../....................
(2) ............................................................................................................... Date ........../........../....................
Section G: Return of Application
Please post this completed application form to:!
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The Registrar! !
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Scan the completed form and email to:!
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Country Network!
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[email protected]
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P.O. Box 105
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Pakenham Vic 3810
Any questions or concerns? Please contact the Registrar. 0433 502 106
New members will receive a “Welcome Pack” which includes the latest published members list, Magazine,
details of our recommended hosting protocols, together with other information aimed at enabling you to get
the most from your membership.!
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(April 2016)
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