Instructions Please complete the form and send the request to the society.
You can either complete the form and print it or print the empty form and complete it by hand. Use the [Print] command on the left and then send it to the address below.
Salutation Mr. Mrs.  Miss.   Ms. 
First Name
Last Name
Contact Information
Address:
Street;
 
 
City
State  PostCode 
Country
Contact:
Phone;
Mobile
Fax
Email 
   
   

I hereby

Nominated

Signed

Seconded

Signed

Areas of Interest
Office Use Only
Application Received Membership Fees Paid
Date Membership Accepted Membership Accepted
Date Letter Sent

Forward your application to

Port Macquarie Historical Society

PO Box 82 Port Macquarie 2444
NSW Australia
Phone 02 6583 1108 Fax 02 6584 7651