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APPLICATION  TO RENEW AFFILIATION  WITH THE PROBUS  ASSOCIATION  OF  VICTORIA  INC.

                               ABN: 51 370 595 374                             Reg. No. A9835                        

The Probus Club of …………………………………………………………………………………………….

desires to become affiliated / renew affiliation (mark as appropriate) with the Probus Association of Victoria Inc. and encloses herewith the appropriate fee of 80 cents per member based on the total membership of the Club as at January 31 and paid by May 31 in same year.

MEMBERS……………………………..at 80 cents = $......................................................

PRESIDENT:………………………………………..................’phone number:……………………...

SECRETARY:……………………………………....................’phone number:………………………

Delegate (1) ………………………………………………………………………..

Delegate (2) ………………………………………………………………………..

Delegate (3) ………………………………………………………………………..

Address for Correspondence:………………………………………………………………..............................

Email:………………………………………………………….......................... Club website URL...................................................

Number of copies of the Victorian Probian required: (multiples of 25)………………

SIGNED: President/Secretary………………………………..……………….Date:………………..

PLEASE COMPLETE THIS FORM AND RETURN IT, TOGETHER WITH THE APPROPRIATE AFFILIATION FEE OF 80 cents PER MEMBER BASED ON THE TOTAL MEMBERSHIP AS AT 31ST JANUARY TO:- MEMBERSHIP, POST OFFICE BOX 2349, Rowville, Vic 3178. PLEASE MAKE CHEQUES PAYABLE TO – PROBUS ASSOCIATION OF VICTORIA INC. ALTERNATIVELY :  DIRECT DEPOSITS MAY BE MADE TO:   BSB 033 169   ACCOUNT NO: 105888   Receipts will not be issued when paid by cheque.

                                                                                      P 2017