Subscription form

Cairns Community Broadcasters Inc.
Raintrees Shopping Centre
PO Box 891 Manunda Qld 4870
Cairns Australia
Ph. (07) 4053 6891 Fax. (07) 4053 2085
Email: info at cairnsfm891.org

Membership Application

Surname: ......................................................................

Given names: ..................................................................

Address: ......................................................................

Suburb: .......................................................................

State: ........... Post code: ............

Home phone: ...................................................
Work phone: ...................................................
Fax (hm/w): ...................................................
Mobile: .......................................................

Email address: ................................................................

Date of birth (optional): .....................................

I understand that, as a presenter, I must abide by the Community Radio Code of Practice, and sign and abide by the station's Statement of Commitment.

....................................
(applicant's signature)

....................................
(proposer's signature)

....................................
(seconder's signature)

For any other information or comments (optional), please fill in the back of this form.

Annual Membership fees from July 1 (incl. GST) are: $20 (full), $10 (conc.).

Board Approval
Office Use only:
Receipt number: ...............

.........................................
(board member's signature)

(date signed): ..........................

Date .........................................
Recpt ........................................
Amt Rec'd ....................................
M'ship 'til .................................