I, …………...........................................………………………… (member of Executive Board), nominate

Name of nominee: …………………..........................................................………………………………...

Address of nominee:…………………………...…………..…......………………………………………………..

......................................................................................................................................................

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

Signed: Nominator (member of Executive Board): ….........................…………… Date: ____/____/____


I accept
Type of membership (tick one)

Ordinary membership Individual Contributing membership
(AUD $1,000 per annum)
Corporate Contributing membership
(AUD $5,000 per annum)		    


Signed: Nominee: …………….......................................................…………….. Date: ____/____/____

 

Contributions for membership are tax deductible in Australia.

For tax deductibility in Australia cheques can be made payable to The John Fawcett Foundation and sent with your nomination form to:

Dr John Lake
Secretary, The John Fawcett Foundation
102 Palmerston Street
Mosman Park, WA 6012
Tel/fax: +61 8 9286 1232