Life membership application

If you would like to become a life member you need to complete your details below and pay online.

Section 1: Applicant's details

Name(Required)

Given name(s) Surname

Gender(Required)

Male

Female

Date of birth(Required)

Address(Required)

Street address 1 Street address 2 Suburb Postcode

Email(Required)

Enter email Confirm email

Mobile number(Required)

Country of birth(Required)

Emergency contact person name(Required)

Emergency contact phone number(Required)

Personal details for immediate family members

Surname

Given name(s)

Relationship

Gender

Date of birth (dd/mm/yyyy)

Section 2: User registration

Username(Required)

Password(Required)

Enter Password Confirm Password

Strength indicator

Section 3: Declaration and consent

Declaration and consent(Required)

As a Life Member, I agree to pay a once-off membership fee of $30. In addition, I am aware this membership does not give me the right to vote as an ordinary member of the Culture Care WA Inc.

I give consent to the Culture Care WA Inc. to send promotional materials and commercial electronic message on Culture Care WA Inc. activities, corporate sponsors to promote their products and services and latest update.

Life membersip fee

Life membership once-off fee $30; plus processing fee $0.83

Price:

Credit Card

Comments

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