Membership Application Form

 I/We _________________________________________________________________________

        would like to register for Membership of the Clan Livingston/Clan MacLea Society of Australia and New Zealand.

 Signature : _______________________  _____________________________

         Please contact Kevin Livingston, 7 Darville Court, Blackmans Bay, Tas. 7052 together with a cheque or postal order for your membership fees and provide the following details :

 Name : _______________________________________

 Address: ______________________________________

                ______________________________________

 Town/Suburb: ______________________________  Post Code: __________

 State: ________________________  Country : ___________________________

 Phone: __________________  Mobile: ________________   FAX: ______________

 Email Address: ________________________________________________________

 Please tick appropriate Box :

Single membership ($25.00)                                              

Couple Membership        ($40.00)                                     

Family Membership         ($40.00)                                   

Overseas Membership     ($50.00)                                     

Permission to publish your name and address in your newsletters? Yes:                   No   

ffice use only

ID:                           ____

Membership no.:      ________

Date:                        __ __/____/________

Receipt No:              ___ ____

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