The Speak Easy
Association of
W.A. Inc
TELEPHONE: (+61) 08 9225 4111
FAX: (+61) 08 9325 7061
33 MOORE STREET, EAST PERTH,
WESTERN AUSTRALIA 6004.
[email protected]
Annual Membership of SEAWA for 2012
Description
Total
Full Membership @ $35 pa
*OR*
Concession Membership @ $20 pa
DONATIONS WELCOME (Tax deductible if $2 or more)
TOTAL PAYMENT REQUIRED:
Please return remittance with payment.
*Complete this grid and keep for your records:
PLEASE RETURN REMITTANCE ADVICE WITH PAYMENT
To:
The Speak Easy Association of WA
33 Moore Street East Perth WA 6004
Description
Total
Full Membership @ $35 pa
*OR*
Concession Membership @ $20 pa
DONATIONS WELCOME (Tax deductible if $2 or more)
TOTAL PAYMENT REQUIRED:
Name:
Address: _____________________________________________________________________
E – mail ______________________________________ Phone Contact _____________________
Method of Payment
Cheque Bankcard Visa Card MasterCard Money Order Name on Card __________________________________________Amount $ _______________________
Signature __________________________
Card Expiry Date _____/_____
 Tick this box if you require a tax invoice to be sent to you after payment has been received
Please disregard this membership renewal form if you have already renewed your membership for this year!
We thank you for your continual ongoing support and have sent you this flier to invite you to come to our
Maintenance Sessions. If you are yet to renew – please do so as soon as you can. We thank you for your
support! If you have an email address – please remember to put this down as most of the notices we send out
now go via email.
OUR MISSION
TO SUPPORT AND HELP PEOPLE WHO STUTTER, TO MAINTAIN FLUENCY AND TO PROMOTE THE TREATMENT OF STUTTERING
THE AUSTRALIAN SPEAK EASY ASSOCIATION IS A REGISTERED CHARITABLE INSTITUTE: REF # DRG 486 946 .